Deptford Center for Rehabilitation and Healthcare
For profit - Limited Liability company
240 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
23/100
#270 of 344 in NJ
Photo by Deptford Center
Photo by Julie Jones
Photo by Deptford Center
1 / 5 photos
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Deptford Center for Rehabilitation and Healthcare has a Trust Grade of F, indicating poor performance with significant concerns about care quality. It ranks #270 out of 344 facilities in New Jersey, placing it in the bottom half, and #8 out of 9 in Gloucester County, suggesting limited better options nearby. While the facility is showing improvement in its overall issues, reducing from 23 in 2024 to just 1 in 2025, there are still serious concerns, such as a critical incident where a resident with swallowing difficulties was given the wrong diet, highlighting potential risks. Staffing appears to be a weakness, with a 70% turnover rate, significantly higher than the state average, and less RN coverage than 91% of other facilities, which can impact resident care. On the positive side, the facility has no fines on record, suggesting some adherence to regulations, and it has received an excellent rating for quality measures, indicating some aspects of care may be performed well despite overall shortcomings.
- Trust Score
- F
- In New Jersey
- #270/344
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 70% turnover. Very high, 22 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most New Jersey facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for New Jersey. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 55 deficiencies on record. Higher than average. Multiple issues found across inspections.
23/100
Bottom 22%
Review needed
23 → 1 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 23 issues
2025: 1 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below New Jersey average (3.2)
Below average - review inspection findings carefully
Staff Turnover: 70%
24pts above New Jersey avg (46%)
Frequent staff changes - ask about care continuity
Staff turnover is very high (70%)
22 points above New Jersey average of 48%
The Ugly 55 deficiencies on record
1 life-threatening 1 actual harm
Feb 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, and policy review, the facility failed to provide quality care in accordance...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, and policy review, the facility failed to provide quality care in accordance with physician orders for one Resident (R) 9) of three residents reviewed for outside appointments out of a total sample of 22 residents. Specifically, the facility failed to ensure R9 had a gastric emptying scan as ordered. This had the potential for R9 and other residents to have medical issues related to missed procedures.
Findings include:
Review of the facility's policy titled, Physician Consultations revised on 08/2019, provided by the Director of Nurses (DON) documented It is the policy of this organization to ensure all residents receive medical care in a timely manner . The attending physician will approve orders based on the consultant recommendations .The attending physician will be responsible for following up on the effects of recommended medications and treatments .
Review of the admission Record under the Profile tab of the electronic medical record (EMR) documented R9 was admitted to the facility on [DATE] with diagnoses Gastroesophageal Reflux Disease (GERD) and anxiety disorder.
Review of the Care Plan under the Care Plan tab of the EMR dated 10/07/24, documented R9 had GERD related to hyper acidity and interventions included obtain and monitor lab/diagnostic work as ordered and refer to Gastroenterologist as needed.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/24 located under the MDS tab of the EMR revealed R9's Brief Mental Status Interview (BIMS) score was 15 out of 15 indicating intact cognition.
Review of R9's Progress Note under the Progress Note tab of the EMR dated 07/31/24 documented, Resident scheduled for gastric emptying scan (gastric emptying study measures how long it takes food to pass from your stomach into your small intestine. The test helps doctors diagnose issues related to slow or rapid stomach emptying. Evaluate symptoms like nausea, vomiting, abdominal pain, or bloating) on August 1st at 8AM .resident and resident's mother notified of upcoming appointment date/time/location.
Review of R9's Progress Note dated 08/01/24 documented, Resident left for appointment via transport.
Review of R9's Progress Note dated 08/01/24 documented, Resident returned via transport.
During an interview on 02/24/25 at 9:56 AM, R9 stated that he/she has nausea and vomiting, believed he/she had abdominal paralysis (a condition where the stomach muscles do not function properly, leading to delayed or incomplete emptying of food into the small intestine), and last year the Physician ordered a gastric emptying test. He/she stated although he/she went to the appointment, he/she vomited prior to the test, which was not able to be completed, was transferred back to the facility, and the test was to be rescheduled. R9 stated although he/she has told several staff he/she still needed the procedure, the test had not been rescheduled.
On 02/26/25 at 8:30 AM, Licensed Practical Nurse (LPN) 6 stated R9 had a gastroenterology appointment on 07/03/24 with a recommendation for a gastric emptying scan on 08/01/24, which was not completed due to R9 vomiting prior to the procedure. She stated when R9 returned to the facility, the scan needed to be rescheduled. LPN6 said she could not recall if she alerted the Medical Records staff to reschedule the test and notified the medical staff. LPN6 stated there was no documentation in the EMR or hard copy chart that the medical staff had been alerted, and the appointment was rescheduled.
Review of R9's appointment log provided by the Medical Records person documented an appointment with the Gastroenterologist on 07/03/024 which was completed and an appointment at the hospital for a test on 08/01/24, which was completed.
During an interview on 02/25/25 at 9:26 AM, the Medical Records person stated she receives information related to outside appointments for residents from the nurses. She stated when R9 refuses a test or consultation, the nurse notifies her, and she reschedules the appointment. She stated she scheduled R9's gastric emptying scan for 08/01/24. The Medical Records person stated she was not notified the gastric emptying test was not completed, assumed it was completed, and therefore, did not reschedule the appointment.
During an interview on 02/26/25 at 11:32 AM, the Director of Nursing(DON) stated R9 had not had his/her gastric emptying scan completed. She stated there was a break in communication between the medical records person and nursing in rescheduling the scan. The DON stated her expectation was that consultations, scans, etc. were completed timely, and the Physician or Nurse Practitioner (NP) was to be notified if there were issues with the completion of consultations and/or procedures.
During an interview on 02/25/25 at 10:10 AM, NP1 stated she was not aware R9 had not had the gastric emptying scan and that the scan had not been rescheduled NP1 stated her expectation was that if R9 did not go to a scheduled appointment and the appointment was not rescheduled, she was to be notified.
NJAC 8:39-27.1(a)
May 2024
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C# NJ166810 C# NJ167847 C# NJ168096
Based on interview, document review, and review of facility policy, the facility failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C# NJ166810 C# NJ167847 C# NJ168096
Based on interview, document review, and review of facility policy, the facility failed to ensure four residents (Resident (R) 6, R9, R25, and R30) of 31 sampled residents reviewed for abuse were free from resident-to-resident abuse perpetrated by R5. This had the potential to affect resident safety at the facility.
Findings include:
Review of R5's electronic medical record (EMR) titled admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia and Alzheimer's disease.
Review of R5's EMR titled Care Plan located under the Care Plan tab, dated 05/07/24, indicated the resident had a history of behaviors such as making false accusations of assault or missing money, yelling at staff and residents, cursing, and aggression toward other residents.
Review of R5's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/03/24 and located under the MDS tab, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period.
1. Review of R6's electronic medical record (EMR) titled admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including lung cancer and dementia.
Review of R6's EMR titled Care Plan located under the Care Plan tab, dated 06/08/23, indicated the resident had a history of behaviors such as using racial slurs, wandering, and cursing at residents. The care plan indicated R6 had severe memory impairment due to her diagnosis of dementia. The care plan indicated the resident was at high risk for experiencing abuse.
Review of R6's EMR annual MDS with an ARD of 05/12/24 and located under the MDS tab, indicated the resident had a BIMS score of six out of 15 which indicated the resident was severely cognitively impaired. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period.
Review of R5's Progress Notes, dated 08/14/23 and located in the EMR under the Progress Notes tab, revealed the resident was involved in a witnessed event during which the resident argued with R6 in the hallway, was separated from R6, and then ran back down the hallway toward R6 and hit R6 on her left shoulder three times.
Review of a document provided by the facility titled Investigation Report, dated 08/16/23, indicated R5 and R6 were immediately separated, and an investigation was initiated related to the alleged abuse. The record indicated no injury to either resident related to the incident. The investigation findings indicated abuse could not be substantiated due to the event was not predictable and was an isolated event. The documentation read, in pertinent part, Any reasonable person would conclude the event was unavoidable due to residents psychiatric diagnosis in conjunction with presenting behaviors.
2. Review of R9's EMR titled admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia and depression.
Review of R9's EMR titled Care Plan located under the Care Plan tab, dated 10/04/23, indicated the resident had a history of experiencing hallucinations and delusions. The care plan indicated R9 was at high risk for experiencing abuse.
Review of R9's quarterly MDS with an ARD of 05/11/24 and located in the EMR under the MDS tab, indicated the resident had a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. The assessment indicated the resident experienced delusions during the assessment reference period.
Review of R5's Progress Notes located in the EMR under the Progress Notes tab, indicated a second event, dated 09/09/23 during which R9 reported R5 entered her room and punched her on her left leg. The record indicated R5 stated she punched R9 on the leg because she thought someone had taken her money.
Review of a document provided by the facility titled Investigation Report, dated 09/10/23, indicated R5 and R9 were immediately separated, and an investigation was initiated related to the alleged abuse. The record indicated no injury to either resident related to the incident. The investigation findings indicated abuse could not be substantiated due to the event was not predictable and was an isolated event. The documentation read, in pertinent part, Any reasonable person would conclude the event was unavoidable due to residents psychiatric diagnosis with presenting behaviors in conjunction with diagnosis of chronic UTIs (urinary tract infections). This was an isolated event.
3. Review of R25's EMR titled admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors.
Review of R25's EMR titled Care Plan located under the Care Plan tab, dated 11/03/20, indicated the resident was severely cognitively impaired and had a history of exhibiting behaviors such as verbal and physical aggression toward other residents. The care plan indicated R25 was at high risk for experiencing abuse.
Review of R25's quarterly MDS with an ARD of 04/01/24 and located in the EMR under the MDS tab, indicated the resident had a BIMS score of 99 (the assessment was not able to be completed due to the resident's poor cognition). The assessment indicated the resident did not exhibit any behaviors during the assessment reference period.
Review of R5's Progress Notes located in the EMR under the Progress Notes tab, indicated a third event, dated 08/19/23 during which R5 was witnessed by staff charging at R25 and repeatedly stabbing him/her with an ink pen, causing two small skin tears on R25's right forearm.
Review of a document provided by the facility titled Investigation Report, dated 08/21/23, indicated R5 and R25 were immediately separated, and an investigation was initiated related to the alleged abuse. R25 was treated for his/her skin wounds. The investigation findings indicated abuse could not be substantiated due to the event was not predictable and was an isolated event. The documentation read, in pertinent part, Any reasonable person would conclude the event was unavoidable due to residents psychiatric diagnosis in conjunction with diagnosis of UTI.
4. Review of R30's EMR titled admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behaviors.
Review of R30's EMR titled Care Plan located under the Care Plan tab, dated 01/06/21, indicated the resident was severely cognitively impaired and had a history of exhibiting behaviors such as yelling out, banging on doors, and raising her fist and yelling at staff. The care plan indicated R30 was at high risk for experiencing abuse.
Review of R30's quarterly MDS with an ARD of 04/29/24 and located in the EMR under the MDS tab, indicated the resident had a BIMS score of three out of 15, which revealed the resident was severely cognitively impaired. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period.
Review of R5's Progress Notes located in the EMR under the Progress Notes tab, indicated a fourth event, dated 09/01/23 during which R5 was witnessed by staff standing over R30, screaming, and cussing and grabbing his/her arm. The documentation indicated R30 was yelling out [R5]'s hurting me! The documentation indicated R30 sustained a superficial scratch to his/her right arm related to the incident.
Review of a document provided by the facility titled Investigation Report, dated 09/02/23, indicated R5 and R30 were immediately separated, and an investigation was initiated related to the alleged abuse. R30 was treated for her skin wound. The investigation findings indicated abuse could not be substantiated due to the event was not predictable and was an isolated event. The documentation read, in pertinent part, Any reasonable person would conclude the event was unavoidable due to residents psychiatric diagnosis with presenting behaviors in conjunction with diagnosis of chronic UTIs.
Review of the facility's Accident/Incident Log and Reportable Events Log, both dated 05/01/23 through 05/20/24, revealed four separate incidents between R5 and different residents during which R5 exhibited abusive behavior to these residents. All the incidents occurred between 08/14/23 and 09/09/23. No further incidents were documented in either of the logs after 09/09/23 related to R5 and resident to resident abuse.
Continued review of R5's record indicated no additional incidents of potential resident to resident abuse involving the resident. The record indicated the last incident of potential resident to resident abuse related to R5 occurred on 09/09/23. The record indicated interventions, such as increased supervision of R5 and moving R5 into a private room immediately across from the nurse's station, had been implemented since 09/09/23 to prevent further incidents.
During an interview on 05/22/24 at 10:30 AM, Unit Manager (UM) 1 indicated she was very familiar with R5 and confirmed R5 had been the instigator in multiple resident-to-resident incidents of abuse during the summer/fall of 2023. She confirmed interventions had been put into place since that time and stated she was not aware of any recent incidents of alleged abuse involving R5. She stated, We have eyes on [R5] at all times. [R5] did have quite a few resident to resident (altercations). [R5] is better now. [R5] seems a little more calm in a private room and we keep [R5] away from other residents, which is his/her preference anyway. We have not had any resident to resident for a while now with [R5]. UM 1 stated R5 getting physical with other residents should be considered abuse.
During an interview on 05/22/24 at 10:40 AM, Certified Nursing Assistant (CNA) 13 confirmed she was familiar with R5 and confirmed R5 had a history of resident-to-resident incidents of abuse in the past. CNA13 stated she had not seen any physical altercations between R5 and other residents in a while. CNA13 stated, [R5] is close (to the nurse's station) and in our line of site now, so we can intervene with him/her before anything even happens. I know [R5] and how to intervene.
During an interview on 05/22/24 at 10:45 AM, CNA14 confirmed she was familiar with R5 and stated R5 had been involved in multiple resident-to-resident physical altercations in the past but stated she had not witnessed any recent events involving R5 and other residents.
During an interview on 05/22/24 at 10:50 AM, Licensed Practical Nurse (LPN) 8 confirmed she was familiar with R5 and stated the resident had been involved in quite a few resident to resident physical altercations in the past, but she had not witnessed anything recently. She stated, We do what we need to calm [R5] down. I cannot pinpoint any physical altercations recently. But [R5] has had in the past. At one point in time there were quite a few .[R5] has a private room now because we couldn't take a chance with roommates, [R5] stays in his/her favorite spot, and [R5] writes notes with his/her pen and a book.
During an interview on 05/22/24 at 11:55 AM, the Director of Nursing (DON) stated the facility's Administrator was the Abuse Coordinator, however she was responsible for ensuring investigations into allegations were completed and completing the investigation findings report based on the investigation results. The DON stated R5 had frequent urinary tract infections, and because of her diagnosis of recurrent UTI's, abuse had not been substantiated for any of the above referenced incidents of resident-to-resident physical abuse. The DON further stated her understanding was if staff had not done anything to purposefully instigate resident to resident abuse between residents, abuse could not be substantiated. She stated, I did not understand that resident to resident abuse was a thing. I was referencing staff in all (of the investigations) and saying that the staff did not coerce any resident to be abusive (and so no abuse occurred).
During an interview on 05/22/24 at 12:30 PM, the Administrator stated his expectation was any resident altercation during which there was an intent to do harm to another person should be considered abuse.
Review of the facility's policy titled, Abuse, dated 12/22 and provided by the facility, indicated The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility; and Physical Abuse: includes hitting, slapping, pinching, scratching, spitting, holding roughly, kicking, etc. It also includes controlling behavior through corporal punishment.
NJAC 8:39-4.1(a)5
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C# NJ165261 C#NJ165932 C#NJ166156 C#NJ166810 C#NJ167718 C#167847 C#NJ168096 C#NJ168350 C#NJ168593 C#NJ171428
Based on interview,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C# NJ165261 C#NJ165932 C#NJ166156 C#NJ166810 C#NJ167718 C#167847 C#NJ168096 C#NJ168350 C#NJ168593 C#NJ171428
Based on interview, document review, and review of facility policy, the facility failed to ensure the facility reported the results of their abuse/neglect investigations to the State Survey Agency (SSA) within five working days for 10 out of 13 residents (Resident (R) 3, R4, R5, R6, R9, R2, R11, R7, R31, R14) reviewed for abuse of 31 sampled residents. This failure had the potential to delay corrective measures and appropriate response to abuse allegations ensuring the safety of the residents.
Findings include:
1. Review of R3's electronic medical record (EMR) titled admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of vascular dementia.
Review of R3's EMR titled Care Plan located under the Care Plan tab, dated 02/19/18, indicated the resident had a history of behaviors such as screaming and cursing at staff. The Care Plan revealed the resident had a history of confabulation (false memory creation).
Review of R3's EMR significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/11/23 and located under the MDS tab, indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15 which revealed the resident was moderately cognitively impaired. The assessment indicated the resident made verbal threats, such as screaming and threatening others.
Review of R3's EMR titled Registered Nurse [RN] Assessment, dated 07/10/23 and located under the Progress Notes tab, indicated the resident informed staff that a Licensed Practical Nurse (LPN) 4 choked her.
Review of a document provided by the facility titled Investigation Report, dated 07/12/23, indicated LPN4 was immediately suspended pending the outcome of the investigation. There was evidence which showed the facility reported the initial allegation made by R3 to the SSA within two hours. There was no evidence in the investigative file which showed the results of the facility's investigation were submitted within five business days to the SSA. No abuse was substantiated, and LPN4 returned to the facility.
2. Review of R4's EMR titled admission Record located under the Profile tab indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of left sided stroke.
Review of a document provided by the facility titled Investigation Report, dated 07/05/23, indicated a family member reported on 07/03/23 that Certified Nursing Assistant (CNA) 3 was rough while providing R4 care while working on the 11:00 PM to 7:00 AM shift. The investigation revealed CNA3 was immediately suspended pending the outcome of the investigation. There was evidence which showed the facility reported the initial allegation made by R4's family member to the SSA within two hours. There was no evidence in the investigative file which showed the results of the facility's investigation were submitted within five business days to the SSA. No abuse was substantiated, and CNA3 returned to the facility.
There were no clinical records which mentioned the allegations made by R4's family member on 07/03/23.
Review of R4's EMR titled Care Plan located under the Care Plan tab, dated 08/02/23, indicated the resident had behaviors such as crying out loud and was accusatory.
Review of R4's EMR titled admission MDS with an ARD of 12/12/23 and located under the MDS tab, indicated the resident had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. The assessment revealed the resident had no behavioral concerns.
Review of R4's EMR titled Nursing Clinical Evaluation, dated 01/15/24 and located under the Progress Notes tab, indicated the family member of the resident reported that the resident was afraid of CNA4 since the staff member allegedly spoke rudely to her and removed the call light from the resident.
Review of a document provided by the facility titled Investigation Report, dated 01/23/24, indicated a family member reported on 01/15/24 that on 01/14/24, during the 11:00 PM to 7:00 AM shift, CNA4 spoke with R4 in an inappropriate manner and then took the resident's call light from her. The investigation revealed CNA4 was immediately suspended pending the outcome of the investigation. There was evidence which showed the facility reported the initial allegation made by R4's family member to the SSA within two hours. There was no evidence in the investigative file which showed the results of the facility's investigation were submitted within five business days to the SSA. No abuse was substantiated, and CNA4 returned to the facility.
During an interview on 05/21/24 at 9:28 AM, the Director of Nursing (DON) stated she reported allegations of abuse to the SSA within two hours. The DON stated she submitted the five-day results of her investigations to the SSA by email but had no evidence to show that the five-day reports were submitted to the SSA.
3. Review of R5's EMR titled admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia and Alzheimer's disease.
Review of R5's EMR titled Care Plan located under the Care Plan tab, dated 05/07/24, indicated the resident had a history of behaviors such as making false accusations of assault or missing money, yelling at staff and residents, cursing, and aggression toward other residents.
Review of R5's EMR annual MDS with an ARD of 03/03/24 and located under the MDS tab, indicated the resident had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period.
4. Review of R6's EMR titled admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including lung cancer and dementia.
Review of R6's EMR titled Care Plan located under the Care Plan tab, dated 06/08/23, indicated the resident had a history of behaviors such as using racial slurs, wandering, and cursing at residents. The care plan indicated R6 had severe memory impairment due to her diagnosis of dementia. The care plan indicated the resident was at high risk for experiencing abuse.
Review of R6's EMR annual MDS with an ARD of 05/12/24 and located under the MDS tab, indicated the resident had a BIMS score of six out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident did not exhibit any behaviors during the assessment reference period.
Review of R5's Progress Notes, dated 08/14/23 and located in the EMR under the Progress Notes tab, revealed the resident was involved in a witnessed event during which the resident argued with R6 in the hallway, was separated from R6, and then ran back down the hallway toward R6 and hit R6 on her left shoulder three times.
Review of a document provided by the facility titled Investigation Report, dated 08/16/23, indicated R5 and R6 were immediately separated, and an investigation was initiated related to the alleged abuse. The record indicated no injury to either resident related to the incident. There was evidence which showed the facility reported the initial allegation of physical abuse of R6 by R5 timely, however there was no evidence in the investigative file to show the results of the facility's investigation were submitted within five business days to the SSA.
5. Review of R9's EMR titled admission Record located under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses including schizophrenia and depression.
Review of R9's EMR titled Care Plan located under the Care Plan tab, dated 10/04/23, indicated the resident had a history of experiencing hallucinations and delusions. The care plan indicated R9 was at high risk for experiencing abuse.
Review of R9's quarterly MDS with an ARD of 05/11/24 and located in the EMR under the MDS tab, indicated the resident had a BIMS score of 14 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident experienced delusions during the assessment reference period.
Review of R5's Progress Notes located in the EMR under the Progress Notes tab, indicated a second event, dated 09/09/23 during which R9 reported R5 entered her room and punched her on her left leg. The record indicated R5 stated she punched R9 on the leg because she thought someone had taken her money.
Review of a document provided by the facility titled Investigation Report, dated 09/10/23, indicated R5 and R9 were immediately separated, and an investigation was initiated related to the alleged abuse. The record indicated no injury to either resident related to the incident. There was evidence which showed the facility reported the initial allegation of physical abuse of R9 by R5 timely, however there was no evidence in the investigative file to show the results of the facility's investigation were submitted within five business days to the SSA.
6. Review of R2's admission Record from the EMR Profile tab showed a facility admission date of 06/16/23 with medical diagnoses that included encephalopathy, pancytopenia, cerebral infarction, traumatic subdural hematoma, and seizures.
Review of the Progress Notes from the EMR Progress Notes tab, showed on 06/21/23 at 10:36 PM, R2 had a fall at 8:40 PM with bleeding from the mouth and a dislodged tooth due to hitting her head on the floor. R2 was sent to the emergency room and admitted with subdural hematoma.
Review of the facility provided investigation report to the State Agency revealed the top sheet of the Reportable Event Record/Report [aka AAS45] showed the date of event was 06/22/23 at 2:00 PM and today's date was documented as 06/24/23. The Investigation Form revealed On 06/21/23 resident [R2's name] was observed walking towards nursing station of unit 2b and falling on the floor. The last page in the file showed R2's representative was notified of the fall on 06/21/23 at 8:44 PM. Further review of the investigation file showed no evidence that the completed five-day investigation was provided to the State Agency.
7. Review of R11's admission Record from the EMR Profile Tab showed a facility admission date of 04/28/23 with medical diagnoses that included asthma, depression, anxiety, dementia, protein calorie malnutrition, cognitive communication deficit, and a language disorder.
Review the Progress Notes from the EMR Progress Notes tab, showed on 10/23/23 at 5:05 PM that R11 was experiencing right lower extremity pain following a fall on 10/22/23. The medical practitioner was notified, and an X-ray was ordered.
A review of the facility provided Reportable Event Record/Report [aka AAS45] showed the date of event from the top line of the report was 10/24/23 and the Today's Date was 10/25/23. Further review showed the X-ray report of the injury was received on 10/24/23. The investigation file did not show evidence of the completed five-day investigation report being provided to the State Agency.
During an interview on 05/22/24 at 11:00 AM, the DON stated .the date of the event on the first page of the AAS45 is when I am first made aware [of the incident]. The date called in on the third page will match the date of the event on the first page, which is when I am made aware and will call it within two hours. When asked if there was any evidence or documentation that the completed five-day investigation was provided to the State Agency, the DON explained that the company deleted emails after 30 days, but she would contact the corporate office to see if there was any way of retrieving emails. At 11:45 AM, the DON stated the regional office advised her there was no way to retrieve the emails. At 12:07 PM, the DON confirmed that there was no evidence of the submission of the final investigation reports to the state agency.
During an interview on 05/22/24 at 12:49 PM regarding the State Agency report investigations, the Administrator stated an expectation that We do reportable, and we do the investigation. As soon as we find something we call it in, within the time frame; the AAS45 is sent in which gives a brief summary and lists interventions. A full investigation is completed and sent [to the State Agency] upon request. The State does not always request a full investigation, but I think [DON's name] sends it in.
8. Review of a document titled the New Jersey Department of Health and Senior Services . Division of Health Facilities Evaluation and Licensing .Reportable Event Record/Report, dated 09/11/23 revealed on 09/08/23 at 9:00 AM, R7 reported he was not receiving his breakfast and care prior to dialysis on Tuesday, Thursday, and Saturday. According to this report, the State Agency (SA) was notified of the allegation on 09/08/23 at 10:30 AM.
Review of the Investigation Form signed by the Director of Nursing (DON) with a signature date of 09/10/23, revealed the investigation was complete. There was no evidence in the report or in the investigation documentation to show the report was submitted to the SA within five days after the initial report.
During an interview on 05/22/24 at 12:51 PM, the DON verified she did not have any evidence to show she submitted the result of the investigation to the SA.
9. Review of a document titled the New Jersey Department of Health and Senior Services . Division of Health Facilities Evaluation and Licensing .Reportable Event Record/Report, dated 10/19/23 revealed on 10/16/23 at 3:00 PM, R31 stated a nurse on the 11:00 PM to 7:00 AM shift made a verbally aggressive comment to her. Review of the report revealed the SA was notified of the alleged abuse on 10/16/23 at 4:00 PM, one hour after R31 made the allegation.
Review of the Investigation Form signed by the DON with a signature date of 10/18/23, revealed the investigation was complete and the verbal abuse could not be substantiated. The investigation report and its attachments did not show that the results of the investigation were sent to the SA within five days after the allegation was received.
During an interview on 05/22/24 at 12:51 PM, the DON verified she did not have any evidence to show she submitted the result of the investigation to the SA.
10. Review of the New Jersey Department of Health and Senior Services .Division of Health Facilities Evaluation and Licensing .Reportable Event Record/Report, dated 02/13/24 with an event date of 02/12/24 at 4:00 PM and completed by the DON revealed staff to resident abuse was alleged. According to the report facility staff was made aware on 02/12/24 by the Ombudsman's office that Resident 14's wife alleged R14 was spoken to in an inappropriate manner by a Certified Nursing Assistant. The family member was unable to provide specific dates. The initial report was made to the State Agency on 02/12/24 at 4:19 PM within an hour of finding out about the allegation from the Ombudsman.
Review of the Investigation form, signed by the DON with signature date of 02/19/24, revealed the investigation was complete. The investigation report and its attachments lacked evidence to support that the results of the investigation were sent to the SA within five days after the allegation was received.
During an interview on 05/22/24 at 12:51 PM, the DON verified she did not have any evidence to show she submitted the result of the investigation to the SA.
Review of the facility's policy titled, Abuse, dated 12/22 and provided by the facility, indicated .The facility prohibits the mistreatment, neglect, and abuse of residents/patients. which strives to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property .The Administrator and Director of Nursing are responsible for investigation and reporting .Report results of investigation to the proper authorities as required by State law . There was no information in the policy which directed the facility to submit the results of their investigation to the State Survey Agency (SSA) within five business days.
NJAC 8:39-9.4(e)
Mar 2024
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of the medical record, it was determined that the facility failed to ensure a resident was dressed appropriately while in common areas of the unit and did n...
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Based on observation, interview, and review of the medical record, it was determined that the facility failed to ensure a resident was dressed appropriately while in common areas of the unit and did not expose him/herself to other residents as well as failed to transport a resident from one area of the facility to another in a dignified manner. This deficient practice was identified for 1 of 48 sampled residents reviewed for dignity, (Resident # 89) and was evidenced by the following:
During the initial tour of the 2nd floor on 02/27/2024 at 10:35 AM, the surveyor observed Resident #89 in Activity room/patient lounge on the 2nd floor in a reclining Geri chair. Resident #89 was dressed in a hospital gown, pulled up and his/her brief exposed to room. 10 other residents were in the room along with activity staff. An unidentified Certified Nursing Assistant (CNA) walked in the room looked at resident and left the room without covering him/her with the blanket.
On 02/27/2024 at 12:20 PM, Resident #89 was pushed forward in the Geri chair out of lounge and put in hallway. Gown was observed to have brown colored stains on it.
On 03/01/24 10:22 AM, the surveyor observed CNA #1 pulling resident #89 backwards down the hallway in his/her Geri chair. During an interview with the surveyor at that time, CNA #1 said no it is not appropriate to pull a resident backwards in Geri chair. CNA #1 went on to say but the wheels are not moving when do it forward.
A review of the admission Record revealed Resident #89 was admitted with diagnoses including but not limited to; Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) and Muscle Wasting.
A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 01/19/2024, revealed Resident #89 had impaired short- and long-term memory. The MDS also indicated Resident #89 had severely impaired cognition. Section GG revealed the resident was dependent on staff for bathing, dressing and used a wheelchair for mobility.
During an Interview with the surveyor on 02/29/2024 at 11:17 AM, CNA #2 was asked what the process is when you report to work. CNA #2 replied we have permanent assignments. I do assignments or another staff for aides. We get the resident ready for breakfast or if going out on appointment. Then we pass trays and help residents to eat and then do ADL's (Activities of Daily living). When asked how you know what care a resident requires, CNA #2 replied I know every patient and what they like. Their preferences in clothes, food, liquids. I can tell other staff what residents need and will give them report if they are not familiar with any resident. I work both units and have great memory. The surveyor asked what care does Resident #89 require? CNA #2 replied he/she is complete care and is confused. I take him/her to the bathroom, wash him/her up. We keep Resident #89 in eye view at nurses' station and if in bed every 30-minute checks. The surveyor asked if Resident #89 has clothes and CNA #2 replied yes, he/she has clothes. I lay the clothes out when I give him/her care. The surveyor asked how is a resident to be dressed when they are in the patient lounge at activities? CNA #2 said yes, it is a must to be dressed in common areas. CNA #2 confirmed yes, he/she should 100 % wear clothes when out of the room. When questioned what if a resident is dressed in a gown and they pull the gown up and their brief is exposed. CNA #2 replied Aide should pull the gown down and make sure the resident is covered. If not aide or nurse, they should tell the nurse/aide. 100 % all staff should intervene if exposing self or brief. No, not supposed to happen. CNA #2 said I think what happens with this resident is 11-7 has him/her in night gown and may put him/her at nurses' station and then 7-3 leaves him/her. He/she should be dressed as he/she has plenty of clothes.
During an interview with the surveyor on 02/29/2024 at 11:36 AM, Licensed Practical Nurse (LPN #1) was asked how should a resident be dressed when they are in common areas or in activities? LPN #1 replied resident should be fully clothed and not in a gown. No one should be in activity with gown on. LPN #1 was questioned What if the gown the resident is in is stained? LPN #1 replied If resident is in gown with stains, someone should take resident and change outfit.
During an interview with the surveyor on 03/04/2024 at 10:10 AM, the Director of Nursing (DON) was asked How are residents to be dressed in common areas of the facility? The DON replied some residents refuse to wear clothing, per their preferences. When asked if Resident #89 can make his/her preferences known the DON responded sometimes Resident #89 can make preference known. The DON confirmed No gown should not be stained. The surveyor asked what if resident is in common area and they pull their gown up and their brief is exposed, what should staff that are present do? I would get a sheet and put over him/her and encourage resident to stay covered so as not to expose in any type of way. The surveyor asked What if resident doesn't have clothes? The DON said We have clothes in basement. We have facility center shirts and sweatpants and donated clothes.
The surveyor asked What is the appropriate way that a resident in a Geri chair should be transported from location to location in the building? The DON replied we use the big black bar and push them forward. When asked if it is appropriate to pull resident backwards the DON replied No mam' not pulled backwards.
NJAC 8:39-4.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based on observations and interviews it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, famil...
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Based on observations and interviews it was determined that the facility failed to maintain the most recent State of New Jersey inspection results in a place readily accessible to the residents, families, and the public. This deficient practice was evidenced by the following:
On 02/27/2024 at 09:00 AM, during initial entrance to the facility the surveyor observed the State Results Binder on a small table next to the reception desk. There was a set of double doors between the lobby and a hallway which led to the nursing units. The doors were locked and required a four-digit code to open the doors to enter the nursing units or to exit back to the entrance lobby, where the binder was located.
On 02/28/2024 at 10:30 AM, the surveyor held a Resident Council meeting with 10 residents. During the meeting the surveyor asked the residents if they were aware of the survey results and the location. Ten of the ten residents told the surveyor they were not aware of the results being accessible to them or a location where they can view the results.
On 03/04/2024 at 2:10 PM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) regarding the accessibility of the binder. The LNHA said himself and the Assistant Administrator were responsible for updating the binder and it was in the entrance lobby. The surveyor also informed the LNHA that the residents were not aware of the survey results being accessible to them. No further information was provided to the surveyor.
NJAC 8:39-9.4 (b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation and interview, it was determined that the facility failed to protect the confidentiality of a resident's health related information. This deficient practice was identified at 1 of...
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Based on observation and interview, it was determined that the facility failed to protect the confidentiality of a resident's health related information. This deficient practice was identified at 1 of 2 nursing stations and was evidenced by the following:
On 03/01/2024 at 12:26 PM, at the 2nd floor nursing station, the surveyor observed a medication cart unattended with the Medication Administration Record (MAR) opened to full view, exposing a resident's personal identification which include the following information: The resident's name, photo, date of birth , medical diagnoses, allergies, diet, and medications. The MAR was displayed on a fixed laptop attached to the top of the medication cart located at the nursing station across from hallway C. The medication cart was locked.
On 03/01/24 at 12:29 PM, the Licensed Practical Nurse (LPN #5) returned to her cart. At that time, the surveyor interviewed LPN #5 who stated, I didn't realize I didn't lock the screen. I should have hidden the screen, I didn't realize. When asked what she should have done, she replied, I should always lock the cart and hide the screen.
On 03/01/24 at 1:41 PM, during an interview with the Director of Nursing (DON), the DON stated that she expects that the MAR is closed to protect the personal identifying health information of the resident and that if left open it violates the Health Insurance Portability and Accountability Act (HIPAA).
A review of a facility policy titled, Non-Disclosure/HIPAA. with a revised date of 10/23, revealed under a policy statement, All residents and facility information must be protected and may not be accessed, released, or used without proper authorization.
NJAC 8:39-4.1 (a)(18)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review, it was determined that the facility failed to provide information and educate residents on the grievance process. This was deficient practice was identified for 1...
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Based on interview and record review, it was determined that the facility failed to provide information and educate residents on the grievance process. This was deficient practice was identified for 10 of 10 residents interviewed (Resident #9, 26, 46, 75, 82, 86, 125, 166, 172, and 446)) on the grievance process during a Resident Council meeting conducted on 02/28/2024 at 10:30 AM and was evidenced by the following:
On 02/28/2024 at 10:30 AM, during the resident council meeting with ten alert and oriented residents, the surveyor asked the residents if they were aware of what a grievance was and how to file a grievance with the facility if necessary. Ten of the ten residents present during the meeting told the surveyor they did not know the definition of a grievance or how to file a grievance or formal complaint in writing. When the surveyor reviewed the resident council meeting minutes for November 2023, December 2023, and January 2024, prior to having the resident council meeting, the minutes did not include education on the grievance process being provided to the residents.
On 02/28/2024 at 12:40 PM, the surveyor reviewed the admission packet that was given to all residents on admission. The packet did not include education on the grievance process.
On 03/01/2024 at 11:44 AM, the surveyor interviewed the Grievance officer who was the Director of Social Services. The surveyor asked how the residents were made aware of the grievance process on admission. The DSW stated, when we do an assessment, they get admission packet that has a page with the grievance process, residents are told they can report it to any of the staff, and anyone can take down a grievance and complete the form. The form will be filled out and forwarded to the correct people. There is a grievance log that is kept. The surveyor requested to view the grievance book, the DSW looked at the book on a shelf and stated, I have to get it together.
On 03/04/2024 at 02:10 PM, the surveyor discussed the concern with the Director of Nursing. The DON stated that the residents did not know what the word grievance pertained to, and the surveyor then told the DON that it was clearly explained to the residents in attendance at the meeting. No other information was provided by the facility.
On 03/05/2024 at 12:32 PM, the surveyor met with the resident council president, Resident #146. During the meeting Resident #146 told the surveyor, I really didn't know we had a grievance officer.
A review of a facility policy titled Grievances with a revision date of 02/01/23. The policy revealed that the facility will assist residents, their representative, family members or resident advocates in filing a grievance/concern form when concerns are expressed. The facility will investigate and resolve resident grievances in a timely manner to ensure residents' safety and protection of the resident rights. Number two of the policy indicated that upon admission, the resident or resident representative are provided with information on how to file a grievance/complaint.
NJAC 8:39-4.1 (a) 35, 13.2 (c)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review it was determined the facility failed ensure a Preadmission Screening and Resident Review (PASARR) one was completed accurately for a newly admitted ...
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Based on observation, interview, and record review it was determined the facility failed ensure a Preadmission Screening and Resident Review (PASARR) one was completed accurately for a newly admitted resident. This deficient practice was identified in 1 of 3 residents reviewed for PASARR (Resident #150) and was evidenced by the following:
On 02/27/2024 at 10:09 AM, during the initial tour of the facility, the resident was sitting in the bed with eyes opened.
A review of the admission Record indicated Resident #150 had medical diagnoses which included but were not limited to :dementia, psychotic disorder (a mental illness), aphasia (inability to express self verbally).
A review of the quarterly Minimum Data Set (MDS), an assessment tool dated 08/04/23, revealed the resident had a Brief Interview of Mental Status of 00 meaning the resident was unable to complete the interview due to severe cognitive impairment.
On 02/28/2024 at 09:45 AM, the facility provided the surveyor with a PASARR one that was completed by the transferring acute care facility prior to entering the current facility. Question one on the PASARR was marked as no for the resident having a mental illness diagnosis or evidence of a major mental illness.
On 02/29/2024 at 09:37 AM, the surveyor reviewed the first comprehensive Minimum Data Set (MDS), an assessment tool dated 08/23/22. Under section I titled active diagnoses it included psychotic disorder as a psychiatric diagnosis. Further review of the MDS list showed that all of Resident #150 MDS completed at the facility from the initial date to February of 2024 included a diagnosis of a psychotic disorder.
On 02/29/2024 at 09:47 AM, the surveyor reviewed the residents' active care plan which showed the following focus: Resident uses psychotropic medications related to mood disorder. Interventions included but were not limited to psychiatry consult as needed, give medications ordered by physician, monitor for targeted behaviors, and monitor and report side effects to the physician. The care plan was initiated on 08/08/22.
On 02/29/2024 at 10:31 AM, the surveyor interviewed the facility Director Social Work (DSW) regarding a resident's PASARR on admission. The DSW stated that the admissions office receives the completed PASARR from the sending facility. It then goes to the DSW and the DSW or the MDS coordinator check the PASARR for accuracy.
On 03/01/2024 at 11:44 AM, the DSW told the surveyor that she would check if residents had a mental illness diagnosis on admission. The surveyor asked about Resident #150 PASARR, and the DSW told the surveyor it was inaccurate and, I believe that would have to be updated.
A review of a facility policy titled PASARR Screens, with last revised date on 12/2023, revealed Under the procedure section of the policy, that the admission department will obtain completed level one screens prior to admission, and upon admission the social worker will be responsible to ensure the completed Level one screen and level two is in the medical record. Number six indicated that the Director of Social work will conduct regular audits to ensure compliance of the screen/PASARR process.
NJAC 8:39-27.1 (a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to devel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical needs and failed to implement focus and interventions that are specific to the resident's catheter care and respiratory diagnosis. The deficient practice was identified for 1 of 2 Residents (Resident # 48) for catheter care and of 2 Residents (Resident #170) for respiratory diagnosis, investigated for care plans.
The deficient practice was evidenced by the following:
1. On 02/27/2024 at 10:43 AM during the initial tour of the facility the surveyor observed Resident # 48 sitting in the dining room. Resident # 48 was observed to have a indwelling catheter (a medical device that helps drain urine from your bladder) in a blue privacy bag.
On 02/29/2024 at 10:40 AM, the surveyor observed Resident # 48 lying in bed. The indwelling catheter was observed in a blue privacy bag attached to the bed frame. Resident # 48 said they cannot have a leg beg due to having a skin graft on his leg.The privacy bag was observed incontact with the floor.
On 03/01/2024 at 10:50 AM, they surveyor observed Resident # 48 walking with the indwelling catheter in the blue privacy bag hanging off another bag around his/her neck.
A review of Resident # 48's admission record revealed that Resident # 48 was admitted to the facility with the following diagnoses but not limited to urinary retention, urinary stricture, or blockage.
A review of Resident # 48's Physicians orders revealed orders for catheter care every shift, monthly indwelling catheter change, indwelling catheter to down drain, and catheter-urinary change urinary collection bag if soiled, broken or with catheter change.
A review of the Annual Resident Assessment Instrument Minimum Data Set (MDS), dated [DATE] revealed Resident # 48 had a Brief Interview for Mental Status Score of 15, indicating they were cognitively intact. Section GG of the MDS revealed Resident # 48 was independent with toileting hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement.
A review of Resident # 48's Care Plan initiated on 12/16/2021, revealed that he/she had an indwelling catheter, but failed to state that the resident did his/her own catheter care.
On 02/29/2024 at 10:40 AM during an interview with the surveyor, Resident # 48 said that they empty their own bag, write down the amount of urine and let the nurse know.
On 3/01/2024 at 11:05 AM during an interview with the surveyor, License Practical Nurse (LPN) #1 replied, [Resident #48] does [his/her] own catheter care. I ask them if it is done and they tell me. Then I check it off on the TAR [Treatment Administration Record]. When asked where it is documented that Resident # 48 can perform their own care, LPN # 1 replied, I don't know, maybe the Care Plan. LPN # 1 also stated, If I see the bag on the floor, I remind them to pick it up.
On 03/04/2023 at 1:49 PM the surveyor interviewed the Director of Nursing (DON). The DON said that Resident # 48 is very adamant on preforming their own catheter care, and that they should have made sure it was in their Care Plan.
A review of a facility provided policy titled, CARE PLANS, COMPRHENSIVE last reviewed on 10/2023 revealed under Procedure 1. the interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 8. The comprehensive, person-centered care plan will: (b) Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing.
2. During the initial tour of the facility on 02/27/2024 at 10:45 AM, the surveyor observed Resident # 170's room. The resident was not in the room at this time. The oxygen concentrator (medical device that delivers oxygen) was on, and the rate was set at 5 liters per minute (lpm).
On 03/01/2024 at 10:21 AM, the surveyor observed Resident #170 in his/her room, sitting on the side of the bed. The resident had a nasal cannula (NC) (a flexible tube that delivers oxygen through your nose) applied to his/her nares which was delivering oxygen at 5 lpm. Resident #170 states that he/she will apply the oxygen when he/she feels they need it. Resident # 170 also said the nurse sets the oxygen rate to five liters and that's what it stays on.
On 03/04/2024 at 9:33 AM, the surveyor observed Resident #170 in his/her bedroom sitting on the side of the bed. Resident #170 has oxygen applied and is being delivered at 5 lpm via NC.
A review of the admission Record located in the electronic medical record (EMR) revealed Resident # 170 was admitted to the facility with the following but not limited to diagnoses: Shortness of breath and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs).
A review of the Quarterly Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, dated 01/19/2024, Resident #170 had a Brief Interview for Mental Status Score of 15, indicating they were cognitively intact. Section I revealed Resident #170 had active diagnoses of but not limited to shortness of breath and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). According to section J of the MDS Resident #170 had shortness of breath when lying flat.
A review of the Physician Order Summary Report (POS) located in the EMR revealed a physician's order started on 12/01/2023 that revealed apply O2 2L as needed to maintain spo2 (measurement of how much oxygen your blood is carrying) greater than 90% as needed for hypoxia (low levels of oxygen in your body tissues).
A review of the Care Plan located in the EMR date initiated on 07/13/2023 with a revised date of 01/25/2024, revealed that there were not any focus, goals or interventions for the respiratory diagnoses or respiratory treatment.
On 03/01/2024 at 10:32 AM, during an interview with Certified Nursing Assistant (CNA) # 3, the surveyor asked who is responsible for monitoring the resident's oxygen concentrator settings. CNA #3 replied, the nurse monitors the resident's oxygen status and oxygen rate. If we see that a residents oxygen rate is being delivered at the wrong rate, we can set it back to what it is ordered for. CNA #3 also said the resident should have a care plan for oxygen use.
On 03/01/2024 at 11:17 AM, during an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) # 1, the surveyor asked what the facility care plan process is. LPN/UM#1 replied, the unit manager completes the baseline care plan upon admission. Some areas that should be included are falls, skin care, incontinence, cancer, oxygen, hospice, smoking and anything that pertains to the resident. The surveyor then asked if there is a new order for oxygen should that be added to the resident's care plan. LPN/UM #1 replied, Yes, if it's a new order the unit manager will update the residents care plan to include the oxygen.
On 3/04/2024 at 10:10 AM, during an interview with Director of Nursing (DON) the surveyor asked what the facility care plan process is. The DON replied, the unit manager will do the initial care plan and will update them as needed. Surveyor then asked what some of the focus areas that are included on the care plan. DON replied, any area that pertains to their medical diagnosis such as pain, skin concerns, falls, equipment like a brace, smoking, psychotropic drugs, foley catheters, and abuse. The surveyor then asked, should there be a care plan for respiratory diagnosis? The DON replied, yes, if they have a medical diagnosis involving respiratory. Surveyor lastly asked, if a resident is diagnosed with COPD, is ordered oxygen as needed, should they have a care plan for that? The DON replied, yes, absolutely.
A review of the facility policy titled: Care Plans - Comprehensive, with a revised date of 10/2023, revealed the following under Procedure.
13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
A review of the facility policy titled: Oxygen Therapy, with a revised date of 9/2022, revealed the following under Policy. Review the resident's care plan to evaluate for any special needs the residents may have.
A review of the facility job description for Licensed Practical Nurse, revealed the following under Departmental. Carry out direct care to residents based on their care plan. Review resident care plans for appropriate resident goals, problems, strengths, approaches, and revisions based on nursing needs.
A review of the facility job description for Unit Manager, revealed the following under Departmental. Responsible for the evaluation and monitoring of all levels of resident care through on-site observations and audits, including the monitoring and the evaluation of Care Plans for quality, appropriateness and effectiveness on their unit. Monitors all residents on oxygen, tube feedings, suctioning, pressure ulcer care protocols, and behavioral problems, and any other residents' needs.
N.J.A.C. 8:39-11.2 (e)2
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to update a care plan for a resident fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined the facility failed to update a care plan for a resident following a hospitalization and change in condition. This deficient practice was identified in 1 of 48 residents reviewed for care plans (Resident #80) and was evidenced by the following:
On 02/27/2024 at 09:22 AM, during the initial tour of the facility Resident #80 was observed in bed with eyes open. The surveyor did not observe a feeding pump or feeding tube supplies in the resident's room. Resident #80 told the surveyor that he/she used to have a feeding tube when they were admitted to the facility, but no longer had a feeding tube and tolerated a regular diet.
Review of the admission Record revealed Resident #80 had medical diagnoses which included but were not limited to Parkinson's disease (disorder of the central nervous system), failure to thrive, and diabetes (abnormal blood sugar levels).
Review of the quarterly Minimum Data Set (MDS), an assessment tool dated 01/21/24 revealed the resident had a Brief Interview of Mental Status of 6/15, meaning the resident had severe cognitive impairment.
Review of the MDS, a quarterly screening dated 09/27/23, section K, Swallowing/Nutritional status was marked as yes for a feeding tube. Review of discharge MDS dated [DATE] was marked as yes for a feeding tube. The surveyor then reviewed the MDS dated [DATE], a five-day assessment. Section K was marked as no for a feeding tube.
On 03/04/2024 at 10:00 AM, the surveyor reviewed the physician orders which showed an order for a regular diet, thin consistency. It was an active order dated 02/23/24.
At the same time the surveyor reviewed the most recent dietician note dated 03/01/2024 which indicated the resident was receiving a regular diet with supplements. The note also revealed the resident was eating better and feeding self.
On 03/04/2024 at 10:44 AM, the surveyor reviewed Resident #80's care plan. It was an active care plan with an initiation date of 06/24/22. A focus area of the care plan was that the resident requires tube feeding related to inadequate intake and the interventions included but were not limited to administer tube feeding and water flushes as ordered and provide local care to the feeding tube site. Another focus of the care plan was that the resident had a potential for fluid deficit related to a feeding tube. Interventions included to monitor fluid intake, vital signs, and notify physician for any changes.
On 03/05/2024 at 10:44 AM, the surveyor interviewed the Director of Nursing (DON) regarding the resident receiving enteral (tube) feeding. The DON told the surveyor that the resident no longer received tube feedings and she removed the feeding tube from the resident care plan. The DON stated, the resident shouldn't have had a feeding tube on his/her care plan, but it was updated. The DON stated the feeding tube was removed during a hospitalization in February of 2024.
A review of a facility policy titled, Care plans Comprehensive and had a revision date of 10/2023. The policy indicated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under number 13 of the policy revealed that assessments of residents are ongoing and care plans are revised as information about the residents and resident's conditions change. Number 14 indicated that the interdisciplinary team reviews and updates the care plan when there has been a change in resident.
NJAC 8:39-11.2 (e)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
During the initial tour of the facility on 02/27/2024 at 10:45 AM, the Surveyor #2 observed Resident #170's room. The resident was not in the room at that time. The oxygen concentrator (medical device...
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During the initial tour of the facility on 02/27/2024 at 10:45 AM, the Surveyor #2 observed Resident #170's room. The resident was not in the room at that time. The oxygen concentrator (medical device that delivers oxygen) was on, and the rate was set at 5 liters per minute (lpm).
On 03/01/2024 at 10:21 AM, Surveyor #2 observed Resident #170 in his/her room, sitting on the side of the bed. Resident #170 had a nasal cannula (NC) (a flexible tube that delivers oxygen through your nose) applied to his/her nares which was delivering oxygen at 5 lpm. Resident #170 states that he/she will apply the oxygen when he/she feels he/she needs it. Resident #170 also said the nurse sets the oxygen rate to five liters and that's what it stays on.
On 03/04/2024 at 9:33 AM, Surveyor #2 observed Resident #170 in his/her bedroom sitting on the side of the bed. Residents' walker is located within arm's reach. Resident #170 has oxygen applied and is being delivered at 5 lpm via NC.
A review of the admission Record revealed Resident #170 was admitted to the facility with the following but not limited to diagnoses: Shortness of breath and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs).
A review of the Quarterly Resident Assessment Instrument Minimum Data Set (MDS), an assessment tool, dated 01/19/2024, indicated Resident #170 had a Brief Interview for Mental Status Score of 15/15, indicating they were cognitively intact. Section I revealed Resident #170 had an active diagnosis of shortness of breath and chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). According to section J of the MDS Resident #170 had shortness of breath when lying flat.
A review of the Physician Order Summary Report (POS) located in the EMR revealed a physician's order started on 12/01/2023 {apply O2 2L as needed to maintain spo2 (measurement of how much oxygen your blood is carrying) greater than 90% as needed for hypoxia (low levels of oxygen in your body tissues)}.
On 03/01/2024 at 10:32 AM, during an interview with Certified Nursing Assistant (CNA #3) Surveyor #2 asked who is responsible for monitoring the resident's oxygen concentrator settings. CNA #3 replied, the nurse monitors the resident's oxygen status and oxygen rate. If we see that a residents oxygen rate is being delivered at the wrong rate, we can set it back to what it is ordered for.
On 03/01/2024 at 11:08 AM, during an interview with Licensed Practical Nurse (LPN #2), Surveyor #2 asked LPN #2 what is the process for administering oxygen. LPN #2 replied, we will obtain a physician's order for the oxygen with the rate and route. Surveyor then asked who is responsible for monitoring the resident's oxygen status and oxygen concentrator settings. LPN #2 replied, the nurse will check the resident's oxygen saturation level according to the physician's orders. The nurse will also check the concentrator to make sure the resident is receiving the proper rate. Surveyor #2 then asked LPN #2 to verify Resident #170's physician order for oxygen. LPN#2 verified that Resident #170 had an order for two liters of oxygen as needed to maintain spo2 greater than 90% as needed for hypoxia. LPN #2 accompanied Surveyor #2 to residents' room to verify Resident #170's oxygen rate on the concentrator. Resident #170 was not in the room at that time. LPN #2 turned on the concentrator and verified that the rate was set at 5 liters. LPN#2 stated, It should be set at two liters according to the physicians order. LPN #2 then adjusted the rate to 2 liters and said, I should have checked it.
On 03/01/2024 at 11:17 AM, during an interview with the Licensed Practice Nurse/ Unit Manager (LPN/UM #1) Surveyor #2 asked what is the process for administering oxygen. LPN/UM #1 replied, there should be a physician's order for oxygen. The order will show up on the residents Treatment Administration Record (TAR) and the nurse should sign off that they have checked the oxygen rate to ensure its correct.
On 03/04/2024 at 10:10 AM, during an interview with the Director of Nursing (DON) Surveyor #2 asked who is responsible for monitoring the resident's oxygen concentrator settings. The DON replied, the oxygen concentrator settings are monitored and frequently checked by the nurse. We also put a white label with the rate on the concentrator that tells staff what the rate should be set at. If the rate on the oxygen concentrator isn't set correctly the nurse should adjust it according to the physician's orders.
A review of the facility policy titled: Oxygen Therapy, with a revised date of 9/2022, revealed the following under Policy. Oxygen is administered according to physician order. Flow rate must be adjusted by a Licensed Nurse.
A review of the facility job description for Licensed Practical Nurse, revealed the following under Departmental. Carry out direct care to residents based on their care plan. Administers medications and treatments according to facility policies and procedures and nursing standards of practice. Performs nursing procedures as required per facility policy and procedure and nursing standards of practice.
NJAC 8:39-27.1
Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure care and services are provided according to accepted standards of clinical practice, specifically by not providing a resident a medication that was available in the automated medication dispenser and failing to follow a physician's order for oxygen administration. The deficient practice was identified for 2 of 2 residents (Resident # 124 & # 170) investigated for Services Provided to Meet Professional Standards.
The deficient practice was evidenced by the following:
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling and provision of care supportive to or restorative of life and wellbeing, and executing medical regimes as prescribed by a licensed or otherwise legally authorized physician or dentist.
Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding, reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist.
A review of Resident # 124's Quarterly Minimum Data Set (MDS) an assessment tool dated 12/21/2023, revealed that he/she had a diagnosis of but not limited to, Chronic Multifocal Osteomyelitis (inflammation or swelling of bone tissue that is usually the result of an infection). The MDS also revealed Resident # 124 was taking an antibiotic medication (medications used to treat bacterial infections).
A review of Resident # 124's Order Summary revealed a Physician's Order for Doxycycline Hyclate (an antibiotic) oral tablet 100 milligrams (MG) to be given by mouth twice daily for osteomyelitis. The order began on 06/29/2023.
A review of Resident # 124's Care Plan initiated on 06/28/2023 revealed a focus of, Alteration in comfort R/T [related to] (potential/actual) Aging Process. The Care Plan revealed an intervention to, Administer medications as ordered.
A review of Resident # 124's Medication Administration Records (MAR) from December, 2023 and January, 2024 revealed that Resident # 124 did not receive the Doxycycline Hyclate on the following dates and times:
12/27/2023 8:00 PM
01/09/2024 8:00 PM
01/10/2024 8:00 PM
01/22/2024 8:00 PM
A review of Resident # 124's Progress Notes located in the Electronic Medical Record (EMR) revealed that on 12/27/2024, 01/09/2024, 01/10/2024, 01/22/2024, the Doxycycline Hyclate was not available, ordered and awaiting delivery from the pharmacy.
A review of the facility provided documents titled, Inventory Snapshot, C11-2 revealed that on the following dates, the automated medication dispenser had at least 9 capsules of Doxycycline Hyclate 100MG. The dates and inventory were as follows:
12/27/2023 - 10 on hand
01/09/2024 - 9 on hand
01/10/2024 - 9 on hand
01/22/2024 - 9 on hand
On 03/04/2024 at 01:24 PM during an interview with Surveyor #1, Licensed Practical Nurse (LPN) # 1 replied, You're supposed to reorder or check the back-stock. when asked by Surveyor #1 what is the expectation if the nurse cannot find a medication in the medication cart. LPN # 1 confirmed by stating, You can check there too. after the Surveyor #1 asked if they can check the automated medication dispenser on the first floor.
On 03/04/2024 at 01:49 PM during an interview with Surveyor #1, the Director of Nursing (DON) replied, Call the physician, notify the physician. First you should check the [brand name; automated medication dispenser] . At that time, the DON replied, Yes. when Surveyor #1 asked if the nurses should be utilizing the medication dispenser system to check for the medication to administer. Finally, after Surveyor #1 revealed the facility's inventory of the Doxycycline Hyclate on the aforementioned dates, Surveyor #1 asked if Resident # 124 should have received the Doxycycline Hyclate 100MG on those dates. The DON replied, Yes.
The facility did not provide a policy for the automated medication dispenser.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that residents with decreased range of motion and mobility received prescribed treatments to prevent contractures for 1 of 4 residents (Resident #112) reviewed for limited range of motion.
This deficient practice was evidenced by the following:
During the initial tour of the facility on 02/27/2024 at 10:36 AM, the surveyor observed Resident #112 lying in bed awake. The resident's left hand was contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity or rigidity of joints) and a right hand deformity was noted. When interviewed the resident stated that he/she had a brace somewhere that staff put on once in a while. The resident further stated that he/she wanted to have it on more frequently. The resident's family member was present and agreed with the resident's statement and expressed a desire for the resident to resume physical therapy services.
On 02/28/2024 at 2:47 PM, the surveyor observed Resident #112 lying in bed and the resident did not have a left hand palm protector on. The resident stated that he/she had not had it on yet. The resident's family member who was present confirmed that the left hand palm protector was not offered to the resident.
According to the admission Record (an admission summary), Resident #112 was admitted to the facility with diagnosis which included but were not limited to: Vascular dementia (dementia caused by an impaired blood supply to the brain), mild, without behavioral disturbance, psychotic disturbance, mood disturbance or anxiety, need for assistance with personal care, depression, and adult failure to thrive.
A review of Resident #112's Quarterly Minimum Data Set (MDS), an assessment tool dated 02/07/24, reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated that the resident was moderately cognitively impaired. Further review of the assessment revealed that the resident had no instances of behavior which included rejection of care. Review of the Functional Limitation in Range of Motion section of the assessment revealed that the resident had bilateral (right and left sides) impairment of the upper extremities (shoulder, elbow, wrist, hand) and lower extremities (hip, knee, ankle, foot).
Review of the Order summary report revealed an active order dated 09/27/22 for a L hand palm protector 10 am-6 pm daily with removal for hygiene as needed and skin checks pre/post application.
Review of Resident #112's February 2024 Treatment Administration Record (TAR) and Medication Administration Record (MAR) indicated that there was no documented evidence that the physician's order for the left hand palm protector was reflected on the TAR or MAR for nursing to document application and usage.
Review of Resident #112's Progress Notes for the month of February 2024, did not include documented evidence that the resident's left hand palm protector was applied in accordance with the physician's order or was refused by the resident.
A review of Resident #112's Care Plan revealed an entry initiated on 07/28/2020 and revised on 11/03/20, with a focus of: Limited physical mobility R/T (related to) hand and feet contractures. Goals included: The resident will remain free of complications related to immobility, including contractures, thrombus (blood clot) formation, skin-breakdown, and falls related injury through the next review date (Target date 05/21/24). Interventions included: L (left) palm protector 10 am-6 pm daily with removal for hygiene as needed and skin checks pre/post application (date initiated 08/20/20) .Adaptive device: L palm protector 10 am-6 pm daily with removal for hygiene as needed and skin checks pre/post application (initiated 11/10/22).
During an interview with the surveyors on 02/29/2024 at 9:59 AM, Certified Nursing Assistant (CNA) #5 stated that Resident #112 required completed care and range of motion to their extremities. CNA #5 stated that the resident also required a hand roll to be placed in their hand after care. CNA #5 stated that the hand roll was stored in the resident's top drawer. When asked when the resident last had the left palm protector (hand roll) on she stated that the resident had it on yesterday. The surveyor stated that the left palm protector was not observed in use as described. CNA #5 then stated that the resident sometimes refused. The survey then asked where CNA #5 documented details of left hand palm protector use. CNA #5 stated that she documented in Plan of Care (POC). CNA #5 then proceeded to show the surveyors the documentation record on the wall mounted computer kiosk and there was no entry noted that pertained to the left hand palm protector usage for CNA #5 to document resident usage or refusal. CNA #5 stated that she last documented it yesterday and on Saturday she might have been able to document usage. CNA #5 further stated that the order may have been removed when therapy was discontinued. CNA #5 stated that the resident did not like it and refused it as he/she did not want it on. CNA #5 further stated that the resident would have it on tomorrow when they got out of bed.
During an interview with the surveyor on 02/29/2024 at 10:05 AM, Licensed Practical Nurse (LPN #6) stated that Resident #112 required complete care, had no behaviors and was complaint with care. LPN #6 stated that the resident did not always like to get out of bed. LPN #6 stated that Resident #112 used a hand roll from physical therapy that might be documented on the TAR. LPN #6 then proceeded to review the TAR in the presence of the surveyors and stated that an order was placed on 09/27/22 for a left palm protector from 10 am-6 pm daily. LPN #6 stated that she saw the palm protector yesterday morning in the bed and was not sure if the resident put it on and took it off. LPN #6 stated that the aide should have documented usage in the POC and nursing should document usage on the TAR. LPN #6 stated that the resident's family member was cognitively intact and could advocate for the resident as he/she was credible.
During an interview with the surveyor on 02/29/2024 at 10:22 AM, the Director of Rehab (DOR) stated that an order was placed for a left palm protector from 10 am to 6 pm with removal for hygiene and skin checks on 09/27/22, by the therapist and was confirmed by the physician. The DOR stated that she would have expected that an aide would have put it on and the nurse would confirm use. The DOR explained that the purpose of the palm protector was to prevent further contracture and protect the skin integrity to prevent the nails from digging into the resident's skin.
During an interview with the surveyor on 03/01/2024 at 10:59 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) #2 stated palm guards were ordered daily from 10 am to 6 pm and was on the [NAME] for the CNA to apply. LPN/UM #2 stated that the aide should document usage and let the nurse know if it were refused.
During an interview with the surveyor on 03/01/2024 at 11:51 AM, the Assistant Director of Nursing (ADON) stated that an order was placed for Resident #112 for a left hand palm protector on 09/27/22 (revision date) to be worn from 10 am to 6 pm. The ADON stated that our POC now had a caveat (stipulation) that asked the aide to answer yes or no to indicate that all care was provided in accordance with the [NAME] for the entire shift that covered all aspects of care on the [NAME]. The ADON reviewed the documentation and indicated that all care was documented as rendered which did not reflect resident refusal. The ADON stated that the resident was care planned for confabulation (false memory without intention of deceit). The ADON stated that the aide should report resident refusal to the nurse. The ADON stated that the resident's family member was protective of the resident and their memory was not consistent.
During an interview with the surveyor on 03/04/2024 at 9:27 AM, the surveyor reviewed Occupational Therapy Evaluation and Plan of Treatment Notes dated 04/04/23, with the DOR which revealed the following: Caregiver inservicing to be completed as appropriate, once orthotic wearing tolerance is determined. Patient previous with left hand palm protector wearing schedule of 10 am to 6 pm daily with removal for hygiene as needed for skin checks pre and post application. Caregiver inservicing completed at that time. Upon review and documentation review this day, resident with documented history of refusal x 5 days in last 14 days, and staff noncompliance per resident's family member. Of note, patient with room change in last three months possibly resulting in need for further caregiver training .The DOR provided the surveyor with a staff in-service Topic: Left hand palm protector 10 am - 6 pm daily with removal for hygiene as needed and skin checks pre/post application, dated 04/06/23 which was signed by CNA #5.
During an interview with the surveyors on 03/04/2024 at 10:27 AM, the Director of Nursing (DON) stated that staff were responsible to follow orders and tasks. The DON stated that therapy educated staff and the order was placed in tasks for the CNA to put on. The DON stated that the Unit Manager as responsible to ensure that the order was on the task (Kiosk) to sign. The DON stated that within the last two weeks as a result of an audit, the orders were placed on the TAR for nursing documentation. The DON stated that an audit was done and it was determined that when the order was placed in the computer the drop down box was not accessed to ensure that the order carried over to the TAR for nursing to document usage. The DON stated that if the resident refused the palm protector then she would have expected that the nurse would have been informed and documented the refusal. The DON stated, If it were not documented, it was not done. The DON explained that the order indicated that the palm protector be placed on 7-3 and removed on 3-11 shifts and since it was not carried over to the POC (tasks) for CNA application it may be a system wide problem. The DON further stated that if the order were not in POC, then the aide may not be aware of the need to apply the palm protector. The DON reviewed the Care Plan in the presence of the surveyors and stated that resident behaviors included refusal of medication, treatments, care and confabulation. We do not go into specifics. The DON stated, The left palm guard care plan entry did not include refusal, but maybe it should have.
Review of the facility policy, Appliances-Sprints [sic.], Braces, Slings (Policy No. CA-27) (Last Date revised 04/2023) revealed the following: In order to protect the safety and well-being of our residents, and to promote quality care, this facility uses appropriate techniques and devices for appliances, splints, braces and slings. To assure all splints, braces, slings etc. are used appropriately and cared for properly and upper and lower extremities are maintained in a functional position.
Procedure:
.Nursing: Ensures proper schedule for donning (put on) and doffing (take off) appliance is known by CNA staff and provides appropriately sign off of task options .
NJAC 8:39-27.2(m)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to maintain a urinary catheter and provide services in a manner consis...
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Based on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to maintain a urinary catheter and provide services in a manner consistent with standards of practice for 1 of 2 residents reviewed for urinary catheter care (Resident #80). This deficient practice was evidenced by the following:
On 02/27/2024 at 09:22 AM, during the initial tour of the facility, Resident #80 was observed in bed with eyes open. The surveyor observed a urinary drainage bag hanging on the left side of the bed facing towards the doorway of the residents' room. The drainage bag was not in a privacy bag, meaning the bag did not have a cover to conceal the contents.
Review of the admission Record revealed Resident #80 had medical diagnoses which included but were not limited to Parkinson's disease (disorder of the central nervous system), and obstructive uropathy (disorder of the urinary tract due to obstructed urinary flow).
Review of the quarterly Minimum Data Set (MDS), an assessment tool dated 01/21/24 revealed the resident had a Brief Interview of Mental Status of 6/15, meaning the resident had severe cognitive impairment. Review of section H, titled bowel and bladder indicated the resident had an indwelling urinary catheter.
On 02/27/2024 at 10:52 AM, the surveyor observed Resident #80. The resident was in the bed as you entered the room. There was a roommate in the second bed. The roommate had two visitors at the time of the observation. The urinary drainage bag was on the left side of the bed, facing the doorway and was not in a privacy bag.
On 02/27/2024 at 11:56 AM, the surveyor interviewed Resident#80 regarding the urinary catheter. Resident #80 told the surveyor they had catheter for, About a year and a half. The surveyor asked if the resident saw a urologist and resident said, I see a kidney doctor, but could not say whether he/she saw a urologist at the time of the interview.
On 02/28/2024 12:07 PM, the surveyor entered Resident #80's room. The resident was in bed with eyes closed. The surveyor observed the urinary catheter drainage bag on the left side of the bed laying on the floor and it was not in a privacy bag.
On 02/28/2024 at 12:17 PM the surveyor interviewed Certified Nursing Assistant (CNA #2) regarding the resident's urinary drainage bag. CNA #2 looked in the resident's room and said, The bag is on the floor, and it doesn't have a privacy bag. The surveyor asked why it shouldn't be that way and she stated, Infection control.
On 02/29/2024 at 01:16 PM, the surveyor reviewed the care plan which showed the following focus: The resident has a Indwelling Catheter R/T (related to) obstructive uropathy. One of the interventions was the following: Catheter Care - Clean around tubing with soap and water, use catheter-secure to upper thigh, place foley bag in a privacy bag while in bed and in wheelchair. Empty urinary bag every shift. It was an active care plan with an initiation date of 03/10/2023.
On 03/04/2024 at 01:02 PM, the surveyor interviewed Registered Nurse/Unit Manager (RN/UM #2) regarding care of urinary catheter bags. RN/UM #2 said, A urinary drainage bag should be in a privacy bag. The surveyor then asked why a urinary drainage bag shouldn't be on the floor and RN/UM #2 responded, Infection control and it can also tear the bag and we will have spillage. The surveyor asked if it was wrong for the bag to be on the floor under the resident's bed and he responded, Correct it shouldn't have been that way and the resident now has a privacy bag.
A review of a facility policy titled Catheter guidelines, with a revision date of 09/11/23, revealed Under the section titled Indwelling urinary catheter management, number 5. revealed that urinary catheter use will adhere to the principles of dignity to include discrete use and privacy (ie. covering urinary catheter drainage bags). Under the section titled Infection Prevention and Control, number 1. indicated that urinary catheter care, utilization and management will follow current infection prevention and control standards of practice to include but not be limited to: a. position urinary drainage bags below the level of the bladder and secure to avoid kinks and tubing obstruction. Do not position catheter drainage bag touching the floor.
NJAC 8:39-19.4 (a), 27.1 (a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow their own policy for storage of respiratory equipment. T...
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Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to follow their own policy for storage of respiratory equipment. This deficient practice was identified for 1 of 2 (Resident #154) residents reviewed for respiratory concerns and was evidenced by the following:
During a tour of the facility on 02/27/2024 at 09:58 AM, Resident #154 was observed in bed.
On 02/29/2024 at 03:19 PM, the surveyor observed the nebulizer machine (a nebulizer machine delivers aerosol medication to the person via a mouthpiece and chamber/cup that holds the medication, via tubing that is attached to the machine. It is used to treat respiratory conditions such as COPD, bronchitis, and asthma.) on an overbed table. The surveyor observed the tubing and mouthpiece of the nebulizer machine exposed to air and uncovered. At that time, the surveyor observed moisture in the chamber of the mouthpiece that was attached to the tubing.
On 03/01/2024 at 08:09 AM, the surveyor observed the tubing and mouthpiece of the nebulizer machine exposed to air and uncovered. The surveyor observed moisture in the chamber of the mouthpiece that was attached to the tubing.
On 03/01/2024 10:26 AM, the surveyor observed the tubing and mouthpiece of the nebulizer machine exposed to air and uncovered. The surveyor observed moisture in the chamber of the mouthpiece that was attached to the tubing. When interviewed at that time, Licensed Practical Nurse (LPN #3) stated that when the nebulizer machine mouthpiece and chamber is not in use, it should be stored in a bag and should be dry when not in use.
On 03/04/2024 at 08:48 AM, the surveyor observed the tubing of the nebulizer exposed to air and uncovered.
A review of the medical record revealed Resident # 154 had diagnoses that included but were not limited to; Chronic Obstructive Pulmonary Disease and Asthma.
The Minimum Data Set (an assessment tool) dated 12/22/23, reflected that this resident had Brief Interview of Mental Status of 15/15 meaning this resident is cognitively intact and utilized Oxygen within the last 14 days.
A review of a Physician Order Sheet (POS) revealed a physician's order dated 6/26/23, which reflected that Resident # 154 was to receive Xopenex Nebulization Solution 0.63 Milligrams/3 Milliliters (a medicine that helps opens the airways), inhale 3 milliliters by nebulization route every 8 hours for wheezing.
During an interview with the surveyor on 03/04/2024 at 01:49 PM, the Director of Nursing (DON) stated that the nebulizer tubing should be in a bag.
During an interview with the surveyor on 03/05/2024 at 10:42 AM, the DON stated that when the nebulizer tubing is not in use, it should be stored dry and in a bag.
A review of a facility policy titled Nebulizer Medication/Covid 19 (last revised 1/2023) reflected under 24. when equipment is completely dry, store in a plastic bag with resident's name and the date on it.
NJAC 8:39-15.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that the resident's prescribed dietary supplement an...
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Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure that the resident's prescribed dietary supplement and preferences were accurately identified and implemented for 1 of 3 residents (Resident #25) reviewed for dining services.
This deficient practice was evidenced by the following:
On 02/27/24 from 11:59 AM to 12:49 PM, the surveyor observed dining services in the first floor main dining room. At 12:19 PM, The surveyor observed a Dietary Aide (DA) as she called out for a condiment cart after the resident's meals had already been served and the residents had begun to eat their meals. The surveyor observed Resident #25's meal ticket and noted that the resident had not received creamer for his/her coffee, salt, pepper and a health shake (dietary supplement). When interviewed at that time, the resident stated that he/she needed assistance to get creamer for their coffee and salt and pepper. The resident was accompanied by another unsampled resident.
On 02/27/24 at 12:34 PM, the surveyor interviewed Dietary Aid (DA) #1 who stated that the resident's meal tickets were printed out of order. DA #1 stated that not everyone had received the items listed on their meal ticket. DA #1 further stated that the person who normally prepared the meal tickets was out today.
On 02/27/24 at 12:49 PM, the surveyor interviewed the Director of Food Services (DFS) who stated that meals were served restaurant style. The DFS explained that the resident's food orders were taken table by table. The DFS stated that beverages were provided first, then when finished, the meal was provided.
On 02/28/24 at 12:12 PM, the surveyor interviewed DA #2 who stated that she reviewed the resident's meal tickets before she brought the items out to the residents.
Review of Resident #25's admission Record (an admission summary) revealed that the resident was admitted to the facility with diagnosis which included but were not limited to: Mild calorie protein malnutrition, anemia (a condition marked by low a deficiency of red blood cells or hemoglobin, responsible for transport oxygen in the blood), unspecified, and Vitamin B 12 (aids in red blood cell production) deficiency anemia.
Review of Resident #25's Annual Minimum Data Set (MDS), an assessment tool dated 12/19/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) Score of 13 out of 15, which indicated that the resident was fully cognitively intact.
Review of Resident #25's Active Physician's Orders revealed that on 12/07/2022, the resident was ordered a Health Shake one time a day for supplement with lunch.
Review of Resident #25's Care Plan revealed an entry that was initiated on 01/21/22, by the Registered Dietician (RD), with a Focus of: The resident has a nutritional problem r/t (related to) low end of BMI (body mass index, a formula used to determine healthy weight range, 18.5-24.9 normal range), malnutrition, muscle loss, weight gain 4% x 1 month. Goal: Receive adequate nutrition and hydration and will have no significant unplanned weight changes through the next review (Target Date: 04/03/24). Interventions/Tasks: .Regular Diet and regular consistency as ordered .health shake as ordered .
Review of Resident #25's February Medication Administration Record (MAR) revealed an entry dated 12/07/22, for Health Shake one time a day for supplement with lunch. Review of the entry revealed the entry was documented to indicate that the resident consumed 100% of the supplement from 02/27/24 through 02/29/24, though the health shake was not provided as indicated per surveyor observation on 02/27/24.
Review of the Progress Notes revealed a Dietary Note dated 02/26/24 at 15:01 (3:01 PM) which indicated the following: Note Text: Update: Wt 143.6 (2/2) (secondary to) wt gain 7.4#/5.4 % x 1 mos (month), significant, BMI 21.2, diet: Regular, yogurt with B (breakfast), health shake at lunch daily (200 cal (calories) 6 g pro(protein) rt (related to) was recently sent out to the ER .Continue current diet as ordered .
On 02/28/24 at 12:17 PM, the surveyor observed Resident #25 seated at a table in the first floor main dining room accompanied by the same unsampled resident. The surveyor reviewed the resident's meal ticket and noted that the resident had not received their health shake. The resident stated that he/she wanted and preferred a vanilla health shake. DA #2 was present at that time, and stated that she offered the resident a health shake, but the resident wanted coffee instead. The resident denied that he/she declined to have a health shake and the unsampled resident who dined with Resident #25 was in agreement with the resident's statement. The unsampled resident had a BIMS score of 15 out of 15, which indicated that the resident was fully cognitively intact. The unsampled resident was listed on the Dining Room List of regular residents who routinely dined in the first floor dining room at lunch time.
On 02/28/24 at 12:22 PM, the surveyor interviewed the DFS who stated that Resident #25 should have had a health shake regardless of other beverages served because it was a nutritional supplement.
On 02/29/24 at 12:31 PM, the surveyor interviewed the Registered Dietician (RD) who stated that Resident #25 was ordered health shakes daily at lunch in December 2022. The RD stated that the health shakes were provided by dietary on the resident's meal tray and the nurses were responsible to document consumption. The RD stated that the resident's weight of 143 pounds and BMI of 21.2 were within the normal range.
On 03/01/24 at 11:41 AM, the surveyor interviewed the Assistant Director of Nursing (ADON) who was present in the first floor dining room. The ADON stated that the dietary staff were responsible to ensure that the resident's received their appropriate diet. The ADON further stated that she was not sure if the dietary staff or nursing was responsible for tray accuracy. The ADON stated that nursing should know who was ordered dietary supplements. The ADON stated between dietary and nursing they should have ensured that the supplements were consumed. The ADON stated that the aide responsible for POC (Plan of Care) should report the amount of supplement consumed by the resident to the resident's assigned nurse. The ADON stated that dietary supplements were given for extra calories and protein that may not be consumed from the meal tray.
On 03/01/24 at 12:51 PM, the surveyor interviewed Licensed Practical Nurse (LPN) #3 who stated that she was assigned to the first floor dining room today. LPN #3 stated that she provided the residents with supplements from her medication cart on the nursing unit if ordered and recorded the amount consumed. LPN #3 stated that the aides reported the amount of the dietary supplement consumed by residents who ate in the dining room if she were not present. The surveyor showed LPN #3 the chocolate health shake, 118 ounce carton that remained unopened on Resident #25's tray. LPN #3 stated that she had not realized that the resident received health shakes from the dining room staff at lunch time. LPN #3 further stated that when she documented the amount of intake consumed by the resident on 02/27/24, it was an error on her part because she thought that the documention referred to the supplement (another brand) that she provided to residents from her medication cart. Review of both the physician's orders and MARS/TARS (Treatment Administration Record), revealed that the resident was not ordered any other type of oral supplement as described by LPN #3.
On 03/04/24 at 11:02 AM, the surveyor interviewed the Director of Nursing (DON) who stated that staff who monitored the dining room were required to report back to the nurse the amount of dietary supplement consumed and the nurse then documented it on the MAR or TAR. The DON stated that the resident should have received a meal ticket, and staff should make sure that the supplement was received. The DON stated that the resident was very confused and refused things. The surveyor informed the DON that the unsampled resident who regularly dined with Resident #25, was fully cognitively intact and validated that the resident was not offered a health shake as indicated on their meal ticket by DA #2.
Review of the facility policy, Nourishments-Supplements Policy No: CN-9, (Last Reviewed 04/2023) revealed the following: To prevent or respond to unplanned and unfavorable weight loss and malnutrition, the Dietician will assess the nutritional status of all residents and recommends supplements as needed with Physician approval.
Supplement:A product intended to add further nutritional value to the present diet. Adequate dietary intake of essential nutrients can help reduce the risk of weight loss, malnutrition, tissue breakdown and diseases .
Procedure: The nursing staff and dietician should observe the resident's fluid and nutritional habits.
.Nursing staff should inform Dietician of resident's poor intake and refer dietician's recommendation to physician.
.Dietician should recommend a dietary supplement as agreed by Physician. Licensed Nurse shall transcribe the order on the MAR.
Licensed Nurse documents tolerance and consumption on the MAR.
Refusals and poorly accepted supplements should be documented on the EMAR (Electronic Medication Administration Record) and reported to the dietician for review.
.Refusal or poor intake acceptance should be reported to the Physician and Dietician for further evaluation.
.The Dietary Department should audit supplements to ensure they are ordered, tolerated and consumed.
NJAC 8:39-17.4(a)(1)
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/28/2024 at 12:02 PM, Surveyor #3 met with Resident #171 who stated that he/she noted stains on the privacy curtain and tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 02/28/2024 at 12:02 PM, Surveyor #3 met with Resident #171 who stated that he/she noted stains on the privacy curtain and that the housekeeper was told. Resident #171 thinks housekeeper is taking care of it. Surveyor #3 observed the privacy curtain with dark brown stains hanging in his/her room.
On 02/29/2024 at 09:58 AM, Surveyor #3 observed the privacy curtain with stains still hanging in Resident #171's room.
On 03/04/2024 at 08:45 AM, Surveyor #3 interviewed Resident #171 who stated that the privacy curtain still was not changed and that he/she has asked the housekeeper three more times.
Surveyor #3's review of Resident #171's quarterly MDS, an assessment tool, dated 12/31/2023 indicated a Brief Interview of Mental Status (BIMS) of 15, indicating intact cognition.
On 03/04/2024 at 09:18 AM, Surveyor #3 interviewed Housekeeper #1 who stated that the porters do the privacy curtains and that she keeps telling them, but they have a million things to do.
On 03/04/2024 at 09:32 AM, Surveyor #3 interviewed the DHKP who stated that they try to wash the privacy curtains every month. She also stated that her and the porters check the curtains to determine which ones need changing. She further stated that she has a log of privacy curtains that have been changed. She denied knowing that Resident #171 wanted his/her curtain changed due to stains.
Surveyor #3 reviewed the privacy curtain log which revealed that Resident #171's curtain had not been changed.
No policy regarding privacy curtains was provided to Surveyor #3.
NJAC 8:39-4.1(a)(12), 27.3(c) 31.4(a)(b)
On 02/27/2024 at 10:25 AM, during the initial tour of the facility, Surveyor # 2 observed a chair in the hallway of the 2C corridor. The chair had a plate left on top of it. The plate had some pasta remaining on it. No residents were in the vicinity at the time of the observation.
On the same date at 10:32 AM, during the initial tour of the facility, Surveyor # 2 observed a chair at the end of the hallway in the 2A corridor. The chair had a smeared brown substance on the seat cushion.
On the same date at 10:34 AM, during the initial tour of the facility, Surveyor # 2 observed a meal tray on a bedside table in the hallway outside of room [ROOM NUMBER]. The plate on the tray contained remnants of scrambled eggs. No residents were in the vicinity at the time of the observation.
Complaint #NJ169732
Complaint #NJ170765
Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a) provide a homelike dining experience on 1 of 2 units, (2nd floor), and b) maintain the facility and equipment in clean and sanitary environment. This deficient practice was identified for 2 of 2 units, (1st and 2nd floor) and was evidenced by the following:
Repeat deficiency from recertification survey of 09/20/2022
a.) During the initial tour of the 2nd floor on 02/27/2024 12:22 PM, Surveyor #1observed the nurse pass the first tray and no placemats observed on the trays. There were no tablecloths on the tables. All food and drinks were left on the tray for all residents and not placed directly on the tables.
On 02/28/2024 at 12:05 PM, the 1st meal truck arrived at the dining room/patient lounge on the 2nd floor. Resident meals were observed being served on trays and not placed directly on the tables.
During an interview with the surveyor on 03/05/2024 at 10:42 AM, Certified Nursing Assistant (CNA # 4) was asked How are trays served in Dining room/patient lounge for meals? CNA #4 responded the ones (residents) that usually eat in Dining Room, their trays come up first. As soon as tray comes up put on bibs, wash hands and serve the trays. The surveyor asked Is the food served on the tray or removed? CNA responded that staff served the food on the tray. CNA #4 responded, correct when asked if the food was left on the tray.
b.1.) During an environmental tour of the 2nd floor on 03/01/2024 at 10:38 AM, the crash cart behind nurses' station was observed to have dust along the black rim on the bottom of the cart. There were dried streaks on red back of cart and black rim at top of cart. The crash cart also had on top of cart is a suction with tubing connected. The end of the tube that would connect to the suction catheter is lying on the base of the machine uncovered and exposed.
During an interview with Surveyor #1 on 03/01/2024 at 11:05 AM, Licensed Practical Nurse (LPN #5) was asked who is responsible for checking and maintaining the crash cart. LPN #5 responded if it is used, we would restock. The 11-7 supervisor would restock.
During an interview with Surveyor #1 on 03/01/2024 at 11:08 AM, Licensed Practical Nurse/Unit Manager (LPN/UM #1), was asked how is the suction machine to be stored? LPN/UM #1 responded It's always been like that. I can get another one and change it if you want. Surveyor #1 again asked is this the way the tubing and suction machine should be stored, and she replied yes, it's always like that.
During an interview with Surveyor #1 on 03/01/2024 at 01:20 PM, the Infection Preventionist (IP) was asked how should a suction machine be stored on the crash cart when not in use? The IP said it should be wrapped in plastic cover. They usually put a trash bag and wrap it. Surveyor #1 asked if it is appropriate to have the tubing attached and lying on the base of the machine? The IP responded No, it should be fresh tubing and should be in the package.
During an interview with Surveyor #1 on 03/04/2024 at 02:11 PM, the Director of Nursing (DON) said the suction tubing is tubing connected at time of emergency. The tubing should not be connected and covered when not in use.
b.2.) On 02/27/2024 at 12:55 PM, Surveyor #1 observed an unsampled resident sitting in his/her wheelchair. The wheelchair had dried debris on wheels, all support pipes.
On 02/28/2024 at 09:23 AM, the unsampled resident's wheelchair still has white stains on cross bars and metal pipes.
During an interview with Surveyor #1 on 03/04/2024 at 09:35, the Director of Housekeeping (DHKP) was asked who is responsible to clean the wheelchair and how often are they done. The DHKP replied our nighttime porter is responsible and they are supposed to be cleaned once a week. The DHKP responded yes, we clean outside of medication carts once a week as well.
A review of the facility Wheel Chair Cleaning Schedule for January revealed the unsampled resident's wheelchair was documented as having been cleaned on 1/9.
A review of the February Wheel Chair Cleaning Schedule revealed the unsampled resident wheelchair was documented as having been cleaned on 2/29.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0728
(Tag F0728)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of other facility documentation, it was determined that the facility allowed Non-Certified Nursin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of other facility documentation, it was determined that the facility allowed Non-Certified Nursing Aides (NAs) to continue working as an NA after the specified 120 days from date of hire. This deficient practice was identified for 7 NAs, (NA1, NA2, NA3, NA4, NA5, NA6, NA7) during the NA review.
This deficient practice was evidenced by the following:
Reference: State of New Jersey Department of Health memo dated [DATE], sent to Nursing Homes included the following:
Facilities are advised as follows:
II. Nurse Aides
Nurse Aides (not TNAs) who are enrolled in a NATCEP program must finish training and pass the nurse-aide written or oral exam and the State approved clinical skills competency exam within the usual 120 days, pursuant to N.J.A.C. 8:39-43.10. After completing the first 16 hours of training, the nurse aide may work in a nursing home while completing the training and testing.
After the surveyor review of NA files provided by the facility, on [DATE] at 12:50 PM the surveyor interviewed the Staffing Coordinator and Human Resources Director who both confirmed:
NA1 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE])
NA2 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE])
NA3 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE])
NA4 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE])
NA5 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE])
NA6 - start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE])
NA 7 start date [DATE] and taken off the nursing schedule on [DATE] (120 days from start date was [DATE])
On [DATE] at 10:02 AM, the Director of Nursing said NA's do not have their own assignments. They are buddied with a Certified Nursing Assistant (CNA). They answer lights, pass water and assist the CNA with care.
On [DATE] at 02:32 PM the surveyor interviewed the DON who stated that the NAs should not have worked as a NA past 120 days.
Review of policy staffing hours revised 04/2023, provided by facility on [DATE] includes:
1. Our facility maintains adequate staffing on each shift to ensure that our residents needs and services are met.
2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outline on the resident's comprehensive care plan.
N.J.A.C. 8:39-43.10
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Repeat deficiency from recertification survey of 09/20/2022
Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide all the i...
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Repeat deficiency from recertification survey of 09/20/2022
Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to provide all the items that were on the corporate menu. This deficient practice occurred during one breakfast meal that was observed on the first floor and was evidenced by the following:
Repeat deficiency from recertification survey of 09/22/2022
1. On 02/28/2024 at 09:24 AM, Resident #146 had not received their breakfast tray at that time. Resident #146 stated that they usually receive breakfast between 9-9:15 AM. The meal cart arrived on the unit at (9:30 AM and Resident #146 received his/her tray at 9:34 AM.) Resident #146 received scrambled eggs, bagel (whole) with cream cheese, an 8-ounce (oz) skim milk, 6 oz coffee, cold cereal portion control, a small muffin, and 4 oz orange juice. The facility menu provided to the survey team from the Director of Food Services (DOFS) revealed the following meal was to be served at breakfast on 2/28/2024: 4 fl oz (fluid ounce) Cranberry Juice, 6 fl oz Oatmeal, Egg Cheese biscuit 1, wheat toast 1 slice, margarine 1, milk 2% 8 fl oz, coffee 6 fl oz, salt 1 pc (portion control), pepper pc, sugar packet. In addition, the alternate meal was listed as Cream of Wheat 6 fl oz, scrambled egg 1/4 c (cup), white toast 1 slice, and margarine 1. Resident #146 did not choose to receive the alternate meal and should have received an egg cheese biscuit as indicated on the regular menu, dated 2/28/2024 at breakfast.
2. On 02/28/2024 at 10:14 AM, the surveyor conducted an interview with the DOFS. The surveyor asked the DOFS why residents received scrambled eggs and not the menu indicated egg/cheese biscuit the DOFS explained, I'm confused, let me go check something. We don't have an egg and cheese biscuit. The meal ticket indicates that we serve scrambled eggs and toast. The surveyor compared the menu provided to the surveyor by the DOFS and the corporate menu dated Week 1, Wednesday Day 4 for [facility name] F/W 23-24 (fall/winter 2023-2024). Review of both menus indicated that the main meal to be served for breakfast on Wednesday Week 1 was to be the following: Cranberry juice, oatmeal, egg cheese biscuit, 2% milk, and coffee. Review of both menus revealed that the alternate menu to be served was cold cereal, cream of wheat, scrambled eggs, white toast, and margarine. Both menus indicated that an egg and cheese biscuit was to be served as the main menu item at breakfast on Wednesday 2/28/2024 according to the corporate week 1 cycle menu. The surveyor asked the DOFS if they had an egg and cheese biscuit available for breakfast as indicated by the corporate cycle menu. The DOFS stated, No, we don't have an egg and cheese biscuit. The surveyor asked the DOFS if the egg cheese biscuit was prepared in house or was a frozen heat and serve product. The DOFS stated, We make them from scratch, not frozen prepared.
The surveyor reviewed the facility policy titled Menu and Preference Policy, last date revised: 3/2023. The following was revealed under the heading POLICY:
Menus shall meet the nutritional needs of residents; be prepared in advance; and be followed.'
NJAC 8:39-17.2(b)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Complaint # NJ00171057
Repeat deficiency from recertification survey of 09/20/2022
Based on observation, interview, record review and review of other facility documentation, it was determined that the...
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Complaint # NJ00171057
Repeat deficiency from recertification survey of 09/20/2022
Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently serve foods at a safe and appetizing temperature. This deficient practice was evidenced by the following:
On 02/27/2024 at 12:14 PM, during the initial tour of the facility Resident #146 stated that the food has improved but we need more variety, and the portions are small. Resident stated that meal trays arrive between 12:15 and 12:45, you never know. Sometimes food is cold, not what menu says is received.
On 2/28/2024 at 10:30 AM, during the resident council meeting 8 of 8 residents attending the resident council meeting complained of cold food to the surveyor.
On 02/28/2024 at 09:13 AM, the surveyor observed residents plates on a pellet covered with the bottom of another pellet.
On 02/28/2024 at 09:24 AM, Resident #146 had not received his/her breakfast tray. Resident stated that they usually receive breakfast between 9-9:15 AM. Resident stated that they start to get a annoyed when the breakfast comes after 9:30 AM. Meal cart arrived on unit at 9:30 AM and staff started to distribute trays at 9:31 AM. Resident #146 received tray at 9:34 AM. Resident tray was observed to be delivered with only a top plastic pellet cover and no bottom pellet, leaving base of plate exposed on the tray surface and allowing heat to escape.
On 02/28/2024 at 12:05 PM the surveyor observed that all meals/trays had no bottom pellets and had bottom pellets covering the food on the plate. The plate was observed to be sitting directly on the meal tray with no bottom pellet in place. The surveyor did not observe any heated element within the pellet.
On 02/29/20924 at 10:59 AM the surveyors entered the kitchen, accompanied by the Director of Food Services (DOFS). The surveyors observed that the food for the lunch meal was on the tray line and covered with aluminum foil. The surveyors observed the [NAME] conduct tray line temperatures at 11:17 AM. The following temperatures were observed:
hamburger: 182 F (Fahrenheit)
tater tots: 180 F
spinach: 179 F
mashed potatoes: 179 F
mechanical hamburger: 190 F
puree hamburger: 185 F
pureed spinach: 179 F
hot dogs: 184
juice: 40 F
Upon completion of the lunch meal temperatures the surveyors exited the kitchen and returned at 02/29/24 at 01:09 PM and observed the lunch tray line actively in progress. The surveyors exited the kitchen at 1:15 PM. The surveyors returned to the kitchen at 1:30 PM to conduct a test tray. The initial food temperatures were conducted at 11:17 AM. The food was present on the tray-line except the hamburgers when the surveyors entered the kitchen. The surveyor observed during the tray-line temperature monitoring that the Food Temperature Log, dated 2/29/24. Menu Week 1 indicated that if the food had been in hot holding for greater than or equal to 2+ hours that food temps should be re-temp. The surveyors entered the kitchen 2 hours post observation of food on the tray-line (11:17 AM). Observation of the Food Temperature Log revealed that no foods had been re-temped after being on the tray-line for 2 plus hours. The surveyor then interviewed the DOFS. On interview the DOFS stated that the food was on the line for greater than 2 hours and that the food temps should have been re-checked.
The following time line was conducted to assess food temperatures at the lunch meal:
02/29/2024 01:44 PM test tray asked to be assembled.
02/29/2024 01:47 PM tray placed on 1 D Unit meal delivery cart.
02/29/2024 01:48 PM tray left kitchen with (2) surveyors and the DOFS accompanying the 1 D Unit meal cart. (1 D unit meal cart is the last meal cart to be delivered.)
02/29/2024 01:49 PM cart dropped off on 1 D Unit.
02/29/2024 01:52 PM last tray passed to resident.
On 02/29/2024 at 01:54 PM the surveyors observed the DOFS conduct food temperatures on the test tray. The following temperatures were observed:
02/29/2024 01:54 PM Spinach: 130.8 F
02/29/20244 01:54 PM Tater tots: 101.5 F
02/29/2024 01:56 PM Hamburger: 98.4 F
02/29/2024 01:56 PM Coffee:155 F
02/29/2024 01:58 PM Juice: 54.5 F
On interview the facility DOFS was asked what the minimum temperatures should be for hot and cold foods. The DOFS responded, We want the food to be delivered at 150-160 F. The surveyors then asked the DOFS why meals were delivered without a bottom pellet. The DOFS responded, A lot of our pellet bottoms are broken so we don't have enough right now for all the plates. I put an order in.
The surveyor reviewed the facility policy titled Food Safety-Food Handling Policy, Last Revised Date: 09/2021. The following was revealed under the heading POLICY:
Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized.
The following was observed under the heading PROCEDURE:
1.
This facility recognizes that the critical factors implicated in foodborne illness are:
b. Inadequate cooking and improper holding temperatures;
The surveyor reviewed the facility policy titled Food Temperatures Policy, Last Date Reviewed: 3/2023. The following was revealed under the heading POLICY:
Food temperatures of food items will be recorded on menu items and substitutions for meal service to maintain a high level of quality assurance and to monitor potentially hazardous food temperatures as per state and federal health regulations thus ensuring that foods are provided in a safe, palatable manner.
The following was revealed under the heading PROCEDURE:
2.
Meal temperatures will be recorded at the beginning of meal service to ensure proper temperatures are achieved and repeated midway through at point of service if meal service exceeds 2 hours.
6. All employees are responsible to notify their supervisor of any food item that does not meet the regulated safe acceptable service ranges (at or below 41 degrees Fahrenheit or above 135 degrees Fahrenheit).
NJAC 8:39-17.4 (a)(2)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interviews, record review, and review of other facility documentation, it was determined that the facility failed to: 1.) donn (put on) the appropriate personal protective equipm...
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Based on observation, interviews, record review, and review of other facility documentation, it was determined that the facility failed to: 1.) donn (put on) the appropriate personal protective equipment (PPE) prior to entering an isolation room to prevent the transmission of infection 2.) maintain proper infection control practices while performing wound care and 3.) maintain proper infection control practices during the dining observation.
This deficient practice was identified for: 1.) 1 of 3 residents (Resident #645) on transmission-based precautions, 2.) 1 of 2 residents observed for wound care (Resident #126), and 3.) 1 of 3 dining rooms observed for meals (first floor dining room).
This deficient practice was evidenced by the following:
1. On 02/28/2024 at 12:33 PM, Surveyor #1 observed a Contact Precautions sign at Resident #645's doorway. Instructions on the sign included, but were not limited to:
Everyone must clean their hands, including before entering and when leaving the room.
Providers and staff must also: put on gloves before room entry.
Discard gloves before room exit.
Put on gown before room entry.
Discard gown before room exit.
On 03/04/2024 at 08:55 AM, Surveyor #1 observed a Contact Precautions sign at the doorway of Resident #645's room. The surveyor also observed the MDS (Minimum Data Set) (an assessment tool) Coordinator taking food into Resident 645's room without donning the proper PPE (equipment used to minimize exposure to hazards and illnesses) or performing hand hygiene prior to entering or upon exiting the room. The surveyor interviewed the MDS Coordinator as she exited the room and she stated that it was okay because she just put the tray down and came right out. She further stated that there was no need for hand hygiene or PPE.
On 02/28/2024 at 01:36 PM, Surveyor #1 reviewed Resident #645's medical record which revealed physician orders for Daptomycin (an antibiotic) to be administered intravenously for twenty-five days for cellulitis (an infection of the skin) and an order for Contact Precautions for MRSA (methicillin resident staphylococcus aureus, a bacterial infection that is resistant to some antibiotics).
A review of Resident #645's care plan with a focus area that included suspected/actual infection MRSA in bilateral lower extremities. Interventions included, but were not limited to Contact precautions, apply gown and gloves before every room entry and remove them prior to exit.
On 03/04/2024 at 10:00 AM, Surveyor #1 interviewed the Director of Nursing (DON) who stated that for contact isolation all the PPE was needed. She further stated that if staff was observed entering a room on contact isolation without hand hygiene or PPE, the staff member would be wrong.
2. A review of Resident #126's admission record indicated that Resident #126 was admitted to the facility with diagnosis which included, but was not limited to, Parkinson's Disease, bipolar disorder, and morbid obesity.
A review of the Resident #126's most recent significant change Minimum Data Set (MDS), a comprehensive assessment tool, dated 1/24/24 indicated Resident #126 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating Resident #126 had severe cognitive impairment, and an unhealed stage three (3) pressure ulcer (bed sore that extends to the fatty layer under the skin) which was being treated with ulcer care, ointments/medications, and had a pressure reducing device for the bed and wheelchair.
A review of Residents #126's care plan included, but was not limited to; a care focus area for alteration in skin integrity, resident has an actual stage 3 pressure injury to the left buttock.
A review of Resident #126's physician order summary (PO) included an order for calcium alginate (used in the fabrication of wound dressings to assist with wound healing) to be applied to left buttock topically every day shift for wound care, cleanses are with wound cleanser, pat dry with gauze, add calcium alginate, and cover with foam dressing daily.
A review of the February 2024 treatment administration record (TAR) indicated the resident's wound care was performed during day shift as ordered.
On 02/29/2024 from 2:02 PM to 3:28 PM, Surveyor #2, in the presence of a federal surveyor, observed License Practical Nurse (LPN #2) perform wound care for Resident #126. LPN #2 began the wound care treatment process by bringing the treatment cart containing the needed supplies to the hallway where Resident #126's room was located and placed it along the wall near the resident's room door.
At 2:35 PM, while gathering supplies including gauze on a clean barrier pad, LPN #2 stepped away from the treatment cart to the other side of the resident's room door to obtain clean disposable gloves from the box of gloves placed outside the resident's room door. She proceeded back to the treatment cart and placed the clean gloves under her left armpit while opening the new package of clean 4x4 gauze pads. She then donned (put on) the gloves and used them to gather the clean gauze intended to be used for the wound care treatment.
At 2:44 PM, LPN #2 entered the resident's room with her treatment supplies, along with a container of disinfectant wipes, marker, and spray bottle of antiseptic spray. She placed these three items on the windowsill as she cleaned and disinfected the tray table to place the clean wound care supplies on.
At 3:07 PM, while performing wound care, LPN #2 went to the room doorway and asked a third certified nursing assistant (CNA#3) to put on appropriate personal protective equipment, including but not limited to a disposable gown and gloves, and enter the room to assist with wound care. CNA #3 entered the room having donned clean gloves, with her gloved hands in her pants pockets. She then walked towards the wound care area and as she walked past the tray table with the clean wound care supplies, she grabbed the table along with the clean barrier pad with the wound care supplies on it with both gloved hands that were in her pocket, to move it to a side in order to pass by to where she was needed.
At 3:19 PM, once completed with the wound care treatment, LPN #2 gathered the re-usable supplies that she had brought into the room, including a container of disinfectant wipes, a bottle of antiseptic wound spray, and a marker, and without disinfecting any of these items brought them back to the clean treatment cart. She placed the antiseptic spray bottle into the cart drawer and the disinfectant wipes and marker on top of the treatment cart.
At 3:28 PM, Surveyor #2 interviewed LPN #2, who confirmed she did not wipe or disinfect these reusable items prior to returning them to the treatment cart, stating I should have wiped them down. Surveyor #2 inquired about placing the clean gloves under her armpit, to which LPN #2 stated, I should not have done that.
On 03/01/2024 at 12:59 PM, in the presence of the survey team, Surveyor #2 interviewed the Infection Preventionist Registered Nurse (IP). The IP stated it is not acceptable for staff to hold clean gloves under their armpit prior to use, or to have their clean gloved hands in their pockets prior to contact with resident care supplies. She stated this could cause risk of spreading bacteria or germs to patients. She continued to include that returning re-usable supplies from a resident's room, particularly after wound care treatment, to a treatment cart without disinfecting is also not acceptable, and could spread bacteria or germs.
3. On 02/27/2024 at 9:00 AM, when Surveyor #3 entered the the facility signage was noted on the interior entrance doors that instructed those who entered to Mask Up in Resident Areas, Masks should be worn in all resident areas regardless of vaccination status. The receptionist advised all who entered to donn (put on) a mask that were available at the reception desk and perform hand hygiene prior to check-in at the kiosk, where a touchless thermometer was in use.
On 02/27/2024 at 11:59 AM, Surveyor #3 observed dining services in the first floor dining room. Surveyor #3 observed Dietary Aide (DA #3) who failed to donn a mask and wore gloves as she served coffee to the residents. When interviewed, DA #3 stated that she had a mask in her pocket, and had forgotten to put it on prior to meal service. DA #3 declined to answer any further questions. The Regional Clinical Manager (RCM) was present, and stated that masks were not required in the kitchen due to social distancing, but were required in the dining room. The RCM provided DA #3 with a mask to wear at that time. A DA called out to the to the RCM and asked if hand sanitizer was available to hand out to the residents who were already seated and were being served.
On 02/27/2024 at 12:14 PM, Surveyor #3 observed Resident #25 and an unsampled resident, who were seated at a table together. They both had already begun to eat their meal when the RCM brought it to a DA's attention that the residents had not received hand wipes. When interviewed, the unsampled resident stated that the facility did not normally provide hand wipes to the residents prior to meal service. The unsampled resident further stated that he/she washed their hands before they went to the dining room. The unsampled resident ambulated with the use of a rolling walker which was observed next to the resident's chair.
On 02/27/2024 12:28 PM, Surveyor #3 interviewed the Director of Food Services (DFS) who stated that DA #3 was responsible for meal preparation and did not donn a mask prior to the meal service because she did not normally serve the residents. DFS stated that it was his fault because there was a call out and he was supposed to serve the residents, but was busy speaking with someone in the kitchen.
On 02/28/2024 at 12:51 PM, Surveyor #3 interviewed the Infection Preventionist (IP) regarding the facility masking policy. The IP stated that staff were supposed to wear masks in all patient areas. The IP stated the minute the dietary staff stepped out of the kitchen they should have had a mask on in order to keep germs to a minimum. The IP further stated that the facility was remained under outbreak status for Covid-19.
At that time, Surveyor #3 asked the IP to describe her expectation for hand hygiene during meal service. The IP stated that residents should have been offered to clean their hands before they received their food. The IP stated if a resident used a rolling walker for ambulation, hand hygiene was essential to keep germs to a minimum. The IP stated that staff were required to perform hand hygiene with hand sanitizer or wipes before they served food and before they fed residents. The IP stated that gloves should not have been worn in the dining room. The IP stated that if gloves were worn, then the staff would have to doff (remove) their gloves and clean their hands, then donn new gloves in between each resident served.
On 03/01/2024 at 11:41 AM, Surveyor #3 interviewed the Assistant Director of Nursing (ADON) who stated that all residents should be offered hand hygiene upon entry to the main dining room. The ADON stated that if not offered, the resident's ended up eating with dirty hands. The ADON further stated that it was an infection control issue if hand hygiene were not offered before the meal.
At that time, the ADON stated that it was not appropriate for staff to wear the same gloves when they touched different people's plates of food. The ADON stated that everyone should perform hand hygiene between residents. The ADON stated that the facility did not encourage anyone to wear gloves when trays were passed to the residents.
On 03/04/2024 at 11:10 AM, Surveyor #3 interviewed the Director of Nursing (DON) who stated that dining room staff were required to wear masks in resident areas in order to protect the residents. The DON stated that gloves should not be worn during meal service for infection control reasons. The DON stated that staff should wash their hands every two to three residents and use hand sanitizer as well. The DON stated that residents should be offered a towelette on entry or at the table as long as it was prior to eating because they could have touched high touch areas and that was an infection control issue. The DON stated that masking had been in place since the first positive case of COVID-19 occurred and remained in place for 14-28 days after.
A review of a facility policy titled, Multiple Drug Resistant Organisms (MDROs), with revised date of 12/4/2023, indicated Contact precautions will be implemented for residents with MDROs when secretions, excretions or drainage CANNOT be contained .
A review of a facility policy titled, Transmission Based Precautions, with revised date of 5/18/2023, indicated under Contact Precautions: Number two Upon entering the room of a resident in contact precautions, healthcare personnel and visitors should don a gown and gloves. Number three Prior to leaving the room of a resident in contact precautions, healthcare personnel and visitors should doff personal protective equipment and perform hand hygiene.
Review of the facility's Wound Care policy with revised date 10/2022, included but was not limited to, wipe reusable supplies with alcohol as indicated (I.e., outsides of containers that were touched by unclean hands, scissor blades, etc.) Return reusable supplies to resident's drawer in treatment cart.
Review of the facility's Infection Prevention and Control policy with revised date 4/26/2023 included but was not limited to, this facility follows infection prevention and control policies, procedures, and practices intended to maintain a safe, sanitary, and comfortable environment while helping to prevent the development and transmission of communicable diseases and infections. This facility follows standards of practice in regards to infection prevention and control as outlined and recommended by the Centers for Disease Control and Prevention, Occupational Health and Safety Administration, and/or state specific infection prevention and control guidance.
A review of a facility policy titled, Hand Hygiene (Policy No: C-IC-6) (Current Revision Date: 05-18-23) revealed the following: The facility adheres to recommendations by the CDC (Centers for Disease Control) for the practice of hand hygiene in accordance with standard and transmission-based precautions.
Hand Hygiene is performed as [sic.] a minimum at these times: .Before and after contact with the resident; .Before meals .
Residents are assisted with and/or reminded to perform hand hygiene .before meals, and as needed or requested .
NJAC 8:39-19.4(a); 27.1(a)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
C/O # NJ171057
Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure to have sufficient ...
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C/O # NJ171057
Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure to have sufficient nursing staff on a 24-hour basis to provide nursing care to the residents.
This deficient practice was evidenced by following:
On 02/28/2024 at 10:30 AM surveyor #2 held a resident council meeting with 10 to 11 residents. Regarding the call bells, all in the group said the wait time was from 2 hours to 4.5 hours waiting for call bell to be answered, especially on evenings and night shift. They further stated, weekends horrible. 5 of 5 residents stated the delay in call bell response time caused a fall or incontinence episode.
On 02/28/2024 at 12:05 PM surveyor #2 met with Resident #171 who stated that he/she constantly hears people calling for help. Resident #171 further stated that he/she hears call bells ringing for long periods of time. He/she thinks that staffing is a problem, and nobody wants to work at the facility. Resident #171 further stated his/her opinion is that the staff is overwhelmed and understaffed and that nurses are always doing doubles.
1.
For the week of Complaint staffing from 03/12/2023 to 03/18/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts and deficient in total staff for residents on 1 of 7 evening shifts as follows:
-03/12/23 had 11 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-03/12/23 had 17 total staff for 189 residents on the evening shift, required at least 19 total staff.
-03/13/23 had 13 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-03/14/23 had 21 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-03/15/23 had 20 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-03/16/23 had 23 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-03/17/23 had 19 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-03/18/23 had 17 CNAs for 194 residents on the day shift, required at least 24 CNAs.
2.
For the week of Complaint staffing from 11/12/2023 to 11/18/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts, deficient in total staff for residents on 2 of 7 evening shifts, and deficient in total staff for residents on 2 of 7 overnight shifts as follows:
-11/12/23 had 9 CNAs for 199 residents on the day shift, required at least 25 CNAs.
-11/12/23 had 18 total staff for 199 residents on the evening shift, required at least 20 total staff.
-11/13/23 had 18 CNAs for 199 residents on the day shift, required at least 25 CNAs.
-11/14/23 had 21 CNAs for 199 residents on the day shift, required at least 25 CNAs.
-11/15/23 had 24 CNAs for 199 residents on the day shift, required at least 25 CNAs.
-11/15/23 had 13 total staff for 199 residents on the overnight shift, required at least 14 total staff.
-11/16/23 had 19 CNAs for 199 residents on the day shift, required at least 25 CNAs.
-11/17/23 had 21 CNAs for 199 residents on the day shift, required at least 25 CNAs.
-11/18/23 had 18 CNAs for 199 residents on the day shift, required at least 25 CNAs.
-11/18/23 had 18 total staff for 199 residents on the evening shift, required at least 20 total staff.
-11/18/23 had 13 total staff for 199 residents on the overnight shift, required at least 14 total staff.
3.
For the week of Complaint staffing from 12/10/2023 to 12/16/2023, the facility was deficient in CNA staffing for residents on 7 of 7 day shifts, deficient in total staff for residents on 2 of 7 evening shifts, deficient in CNAs to total staff on 1 of 7 evening shifts, and deficient in total staff for residents on 6 of 7 overnight shifts as follows:
-12/10/23 had 12 CNAs for 198 residents on the day shift, required at least 25 CNAs.
-12/10/23 had 16 total staff for 198 residents on the evening shift, required at least 20 total staff.
-12/10/23 had 7 CNAs to 16 total staff on the evening shift, required at least 8 CNAs.
-12/10/23 had 13 total staff for 198 residents on the overnight shift, required at least 14 total staff.
-12/11/23 had 16 CNAs for 198 residents on the day shift, required at least 25 CNAs.
-12/12/23 had 15 CNAs for 198 residents on the day shift, required at least 25 CNAs.
-12/12/23 had 13 total staff for 198 residents on the overnight shift, required at least 14 total staff.
-12/13/23 had 23 CNAs for 198 residents on the day shift, required at least 25 CNAs.
-12/13/23 had 11 total staff for 198 residents on the overnight shift, required at least 14 total staff.
-12/14/23 had 22 CNAs for 198 residents on the day shift, required at least 25 CNAs.
-12/14/23 had 13 total staff for 198 residents on the overnight shift, required at least 14 total staff.
-12/15/23 had 19 CNAs for 199 residents on the day shift, required at least 25 CNAs.
-12/15/23 had 19 total staff for 199 residents on the evening shift, required at least 20 total staff.
-12/15/23 had 12 total staff for 199 residents on the overnight shift, required at least 14 total staff.
-12/16/23 had 18 CNAs for 199 residents on the day shift, required at least 25 CNAs.
-12/16/23 had 11 total staff for 199 residents on the overnight shift, required at least 14 total staff.
4.
For the 3 weeks of Complaint staffing from 01/21/2024 to 02/10/2024, the facility was deficient in CNA staffing for residents on 14 of 21 day shifts, deficient in total staff for residents on 2 of 21 evening shifts, deficient in CNAs to total staff on 1 of 21 evening shifts, and deficient in total staff for residents on 12 of 21 overnight shifts as follows:
-01/21/24 had 12 CNAs for 190 residents on the day shift, required at least 24 CNAs.
-01/21/24 had 13 total staff for 190 residents on the overnight shift, required at least 14 total staff.
-01/22/24 had 11 CNAs for 190 residents on the day shift, required at least 24 CNAs.
-01/22/24 had 9 CNAs to 21 total staff on the evening shift, required at least 10 CNAs.
-01/22/24 had 12 total staff for 190 residents on the overnight shift, required at least 14 total staff.
-01/23/24 had 16 CNAs for 190 residents on the day shift, required at least 24 CNAs.
-01/24/24 had 22 CNAs for 190 residents on the day shift, required at least 24 CNAs.
-01/25/24 had 22 CNAs for 192 residents on the day shift, required at least 24 CNAs.
-01/25/24 had 12 total staff for 192 residents on the overnight shift, required at least 14 total staff.
-01/26/24 had 20 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-01/26/24 had 11 total staff for 189 residents on the overnight shift, required at least 13 total staff.
-01/27/24 had 22 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-01/28/24 had 8 CNAs for 188 residents on the day shift, required at least 23 CNAs.
-01/28/24 had 9 total staff for 188 residents on the overnight shift, required at least 13 total staff.
-01/29/24 had 12 CNAs for 188 residents on the day shift, required at least 23 CNAs.
-01/29/24 had 11 total staff for 188 residents on the overnight shift, required at least 13 total staff.
-01/30/24 had 16 CNAs for 188 residents on the day shift, required at least 23 CNAs.
-01/30/24 had 11 total staff for 188 residents on the overnight shift, required at least 13 total staff.
-02/01/24 had 13 total staff for 192 residents on the overnight shift, required at least 14 total staff.
-02/03/24 had 19 CNAs for 192 residents on the day shift, required at least 24 CNAs.
-02/03/24 had 11 total staff for 192 residents on the overnight shift, required at least 14 total staff.
-02/04/24 had 12 CNAs for 192 residents on the day shift, required at least 24 CNAs.
-02/04/24 had 17 total staff for 192 residents on the evening shift, required at least 19 total staff.
-02/04/24 had 11 total staff for 192 residents on the overnight shift, required at least 14 total staff.
-02/05/24 had 16 CNAs for 192 residents on the day shift, required at least 24 CNAs.
-02/06/24 had 18 CNAs for 191 residents on the day shift, required at least 24 CNAs.
-02/08/24 had 16 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-02/09/24 had 17 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-02/09/24 had 12 total staff for 189 residents on the overnight shift, required at least 13 total staff.
-02/10/24 had 12 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-02/10/24 had 18 total staff for 189 residents on the evening shift, required at least 19 total staff.
-02/10/24 had 10 total staff for 189 residents on the overnight shift, required at least 13 total staff.
5.
For the 2 weeks of staffing prior to survey from 02/11/2024 to 02/24/24, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts, deficient in total staff for residents on 3 of 14 evening shifts, deficient in CNAs to total staff on 2 of 14 evening shifts, and deficient in total staff for residents on 12 of 14 overnight shifts as follows:
02/11/24 had 14 CNAs for 189 residents on the day shift, required at least 24 CNAs.
-02/11/24 had 18 total staff for 189 residents on the evening shift, required at least 19 total staff.
-02/11/24 had 10 total staff for 189 residents on the overnight shift, required at least 13 total staff.
-02/12/24 had 15 CNAs for 188 residents on the day shift, required at least 23 CNAs.
-02/13/24 had 22 CNAs for 188 residents on the day shift, required at least 23 CNAs.
-02/13/24 had 12 total staff for 188 residents on the overnight shift, required at least 13 total staff.
-02/14/24 had 22 CNAs for 188 residents on the day shift, required at least 23 CNAs.
-02/15/24 had 19 CNAs for 188 residents on the day shift, required at least 23 CNAs.
-02/15/24 had 12 total staff for 188 residents on the overnight shift, required at least 13 total staff.
-02/16/24 had 21 CNAs for 195 residents on the day shift, required at least 24 CNAs.
-02/16/24 had 12 total staff for 195 residents on the overnight shift, required at least 14 total staff.
-02/17/24 had 15 CNAs for 195 residents on the day shift, required at least 24 CNAs.
-02/17/24 had 11 total staff for 195 residents on the overnight shift, required at least 14 total staff.
-02/18/24 had 12 CNAs for 195 residents on the day shift, required at least 24 CNAs.
-02/18/24 had 12 total staff for 195 residents on the overnight shift, required at least 14 total staff.
-02/19/24 had 18 CNAs for 195 residents on the day shift, required at least 24 CNAs.
-02/19/24 had 12 total staff for 195 residents on the overnight shift, required at least 14 total staff.
-02/20/24 had 13 CNAs for 195 residents on the day shift, required at least 24 CNAs.
-02/20/24 had 10 total staff for 195 residents on the day shift, required at least 14 total staff.
-02/21/24 had 19 CNAs for 195 residents on the day shift, required at least 24 CNAs.
-02/21/24 had 8 CNAs to 19 total staff on the evening shift, required at least 9 CNAs.
-02/21/24 had 12 total staff for 195 residents on the overnight shift, required at least 14 total staff.
-02/22/24 had 20 CNAs for 195 residents on the day shift, required at least 24 CNAs.
-02/22/24 had 18 total staff for 195 residents on the evening shift, required at least 19 total staff.
-02/22/24 had 12 total staff for 195 residents on the overnight shift, required at least 14 total staff.
-02/23/24 had 19 CNAs for 207 residents on the day shift, required at least 26 CNAs.
-02/23/24 had 10 CNAs to 22 total staff on the evening shift, required at least 11 CNAs.
-02/23/24 had 11 total staff for 207 residents on the overnight shift, required at least 15 total staff.
-02/24/24 had 11 CNAs for 207 residents on the day shift, required at least 26 CNAs.
-02/24/24 had 19 total staff for 207 residents on the evening shift, required at least 21 total staff.
-02/24/24 had 9 total staff doe 207 residents on the overnight shift, required at least 15 total staff.
On 03/04/2024 at 10:47 AM, the surveyor interviewed the staffing coordinator who stated that the CNA ratios are of 1 to 8 on day shift, 1 to 10 on evening shift, and 1 to 14 on night shift. She also stated that one LPN on each hall is ideal for 7-3 and 3-11 shifts. She further stated the facility has a 3-11 supervisor Monday through Friday and that day shift has Unit Managers also Monday through Friday. She also stated that on the 11-7 shift they staff four nurses (2 upstairs and 2 downstairs) and a RN supervisor.
On 03/05/2024 at 09:28 AM, the surveyor interviewed the Director of Nursing regarding minimum staffing. She stated that the facility is separated into 4 units, 1A/1B, 1C/1D, 2A/2B, and 2C/2D. During the day shift Monday through Friday there should be eight to nine nurses in addition to four unit managers, on the evening shift eight nurses plus one supervisor, and on the night shift four nurses plus one supervisor. On the weekend day shift there should be eight nurses and one supervisor. She also stated that there should be four CNAs on each unit on each shift. She also stated that the shortage is all over and the management staff come in when needed to fill in; however, payroll will not show that expectations are met and will show staffing below the minimum required.
A review of a facility policy titled staffing hours with revised date of 04/2023, includes:
1. Our facility maintains adequate staffing on each shift to ensure that our residents needs and services are met.
2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outline on the resident's comprehensive care plan.
NJAC 8:39-5.1(a), 25.2 (b), 27.1 (a)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected most or all residents
Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the narcotic Shift Count logs were completed in accordance with...
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Based on observation, interview, and pertinent record review, it was determined that the facility failed to ensure the accountability of the narcotic Shift Count logs were completed in accordance with facility policy and accurately account for and document the administration of controlled medications. This deficient practice was identified on 4 of 4 medication carts observed on 4 of 4 nursing units and was evidenced by the following:
Repeat deficiency from recertification survey of 09/20/2022
On 2/28/2024 at 11:00 AM, the surveyor, in the presence of a second state surveyor and a federal surveyor, interviewed Licensed Practical Nurse (LPN #4), who stated nurses coming on duty along with the nurse going off duty are to count the narcotics in the medication cart together and sign the Shift Count log together to confirm the count is accurate and narcotics are accounted for. She confirmed there should be no missing documentation or blank sections for each shift change. At this point the surveyor, along with LPN #4, reviewed the medication cart and narcotic logs as well as the shift count logs for nursing unit 1A medication cart 1A - back. The following was observed:
1. 02/05/2024: 11 PM and 2/15/24: 11 PM shift count was not documented.
2. The columns labeled EDK box sealed? and is count correct? were blank for 2/7/24: 7 AM and 2/23/24: 7 AM.
3. Coming on duty nurse's signature was missing for 2/9/24: 11 PM
4. Going off duty Nurse's signature was missing for 2/27/24: 7 AM
On 02/28/2024 at 11:41 AM, in the presence of a second state surveyor, the surveyor interviewed LPN #3, who confirmed that narcotic shift count logs are to be completed by the incoming and outgoing nurses, together upon reconciling the medication cart's narcotics at the change of each shift and should not be pre-signed or completed. She further stated that declining inventory logs (logs to account for individual narcotics for each resident) are to be completed for each dose of that medication, immediately once it has been dispensed from its packaging prior to administering it to the resident. At this point the surveyor along with LPN #3 reviewed nursing unit 1C's medication cart and narcotic logs. The following was observed on the Shift Count log:
1. The columns labeled EDK box sealed? and is count correct? were blank
for 2/4/24: 3 PM, 2/11: 7 AM, 2/11: 3 PM, 2/18: 7 AM, 2/21: 3 PM, 2/25: 7 AM, 3 PM, and 11 PM.
2. Coming on duty nurse's signature was missing for 2/12: 11 PM
3. Going off duty Nurse's signature was missing for 2/21: 11 PM
4. 2/24: 11 PM shift count was not documented.
5. 2/28: 3 PM going off duty nurse's signature and EDK box sealed? and is count correct? columns were pre-filled and pre-signed.
The following narcotic medications and doses were signed in the medication administration record (MAR) as being administered, but not documented as being dispensed in their corresponding declining inventory logs:
1. Resident #29's diazepam 5 milligram (mg) (a medication used to treat anxiety) 2/28/24: 7-10 AM.
2. Resident #44's tramadol 50 mg (a medication used to treat pain) 2/28/24: 9 AM.
3. Resident #82's tramadol 50 mg 2/28/24: 9 AM.
4. Resident #148's lacosamide 150 mg (a medication used to treat seizures) 2/28/24: 9 AM.
On 02/28/2024 at 12:29 PM, in the presence of a second state surveyor, the surveyor interviewed LPN #1, who confirmed that narcotic shift count logs are to be completed by the incoming and outgoing nurses, together upon reconciling the medication cart's narcotics at the change of each shift and acknowledged that if it's not documented it's not done. At this point the surveyor along with LPN #1 reviewed nursing unit 2A's medication cart and narcotic logs. The following was observed on the Shift Count log:
1. Going off duty Nurse's signature was missing for 2/4: 11 PM, 2/5: 7 AM, 2/9: 11 PM, 2/12: 11 PM, 2/13: 11 PM, 2/14: 7 AM,
2. Coming on duty nurse's signature was missing for 2/6: 11 PM, 2/9: 11 PM, 2/13: 3 PM, 2/27: 7 AM.
3. The columns labeled EDK box sealed? and is count correct? were blank for 2/7: 11 PM, 2/9: 11 PM, 2/13: 11 PM, 2/14: 7 AM, 2/18: 11 PM, 2/21: 3 PM, 2/22: 7 AM, 3 PM, 2/27: 7 AM.
4. 2/27: 3 PM, and 2/28: 7 AM shift counts were not documented.
On 02/28/2024 at 1:01 PM, in the presence of a second state surveyor, the surveyor interviewed LPN #2, who confirmed that narcotic shift count logs are to be completed by the incoming and outgoing nurses, together upon reconciling the medication cart's narcotics at the change of each shift and there should be no missing documentation. At this point the surveyor along with LPN #2 reviewed nursing unit 2D's medication cart and narcotic logs. The following was observed on the Shift Count log:
1. Going off duty Nurse's signature was missing for 12/23/23: 11 PM, and 2/20/24: 11 PM.
2. Coming on duty nurse's signature was missing for 12/23/23: 3 PM, and 2/28/24: 7 AM.
3. 2/28: 3 PM going off duty nurse's signature was pre-signed.
On 02/28/2024 at 1:55 PM, the surveyor, in the presence of a second state surveyor, interviewed the Director of Nursing who stated, that the expectation is that the nursing unit managers are to check the narcotic logs daily to ensure the signing in and out of narcotics and shift to shift reconciliation logs are being completed. She further stated there should be no missing documentation at all and the purpose of the narcotic logs is to maintain accountability of the controlled medications. She confirmed there should be no pre-signed signatures for end of shift, and declining inventory logs should be filled out immediately once the medication dose is dispensed from the packaging.
On 02/29/2024 at 12:30 PM, the surveyor, in the presence of a federal surveyor, interviewed the facility's pharmacy consultant pharmacist (RPh) by telephone, who stated narcotic logs should not have blanks or dots, and declining inventory logs should be completed immediately once the medication is poured or dispensed, not at the end of pass.
Review of the facility's Controlled Substance Management policy with a last revised date of 8/2023 included but was not limited to,
2. Separate records shall be maintained on all controlled substances in the form of a declining inventory record. Such record shall be accurately maintained and shall include.
a. the name of the resident.
b. the name of the prescriber
c. the prescription numbers
d. the drug names
e. the form of the medication
f. the strength of the medication
g. the strength of the dose administered.
h. the date and time of administration
i. the signature of the person administering the drug.
3. Such records shall be reconciled by the incoming and outgoing nurse. Two nurses must count the remaining medication at each shift, and any handoff of narcotic keys .
The section titled accounting procedures further included,
1. All controlled substances shall be counted at the change of each shift by the incoming and outgoing nurse.
NJAC 8:39-29.7(c)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) properly store and secure medications and properly label opened multidose...
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Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to a.) properly store and secure medications and properly label opened multidose medications and b.) properly secure wound treatment carts when not attended. This deficient practice was observed in a.) 2 of 2 medication storage rooms and 4 of 4 medication carts on 4 of 4 nursing units reviewed for medication storage and labeling and in b.) 1 of 1 treatment carts observed during wound observation. This was evidenced by the following:
Repeat deficiency from recertification survey of 09/20/2022
a.) On 02/28/2024 at 9:39 AM, the surveyor, in the presence of a second state surveyor and a federal surveyor, interviewed Registered Nurse/Unit Manager (RN/UM #1), who stated all nurses are responsible to maintain the medication storage room's organization and cleanliness. She added that there should be no open medication containers in the storage room and any multidose medications that are stored in the medication room or refrigerator should be labeled and dated with the date opened. The RN/UM1 stated the medication refrigerator temperature is checked daily on the 11 PM nursing shift to ensure proper temperatures are maintained for refrigerated medications. At this point the surveyor, in the presence of the second state surveyor, federal surveyor, and RN/UM #1, reviewed the first floor's medication storage room. The following was observed:
1. One opened multi-dose vial of tuberculin purified protein derivative (an injectable medication used to test for tuberculosis infection) stored in the refrigerator and undated with the date it was opened. To which the RN/UM #1 confirmed should have been dated.
2. One opened bottle of ibuprofen 200 milligram (mg) tablets (medication used for pain) dated with opened date 1/28 and stored with unopened medication bottles. To which the RN/UM #1 stated it should not be in the medication room, rather in the medication cart.
3. Two opened boxes of bisacodyl 10 mg laxative suppository 12 count, each box containing eight (8) and undated.
4. One large clear plastic, resealable bag with a pharmacy prescription label which indicated which resident the contents were prescribed and contained three cefapime (antibiotic) 2-gram (g) vials prescribed for a different resident. To this the RN/UM #1 stated she was unsure why these medications were stored that way and should be returned to the pharmacy.
Further review of the February 2024 medication refrigerator temperature monitoring log indicated the following temperatures in degrees Fahrenheit (F):
2/1: 33
2/2: 34
2/4: 35
2/6: 31
2/7: 35
2/8: 35
2/9: 33
2/10: 31
2/11: 32
2/12: 31
2/13: 33
2/15: 35
2/18: 32
2/19: 34
2/20: 33
2/21: 30
2/22: 30
2/23: 29
2/24: 27
2/25: 28
2/26: 27
2/27: 29
On 02/28/2024 at 10:25 AM, the surveyor, in the presence of a second state surveyor interviewed RN/UM #2, who stated everyone with access to the medication storage room, including nurses, are responsible to maintain the medication storage room's organization and cleanliness. He confirmed that there should be no open medication containers in the storage room and any multidose medications that are stored in the medication room or refrigerator should be labeled and dated with the date opened. The RN/UM #2 stated the medication refrigerator temperature is checked daily on the 11 PM - 7 AM nursing shift to ensure proper temperatures are maintained for refrigerated medications and verified by the unit manager on the 7 AM - 3 PM shift.
At this point the surveyor, in the presence of the second state surveyor and RN/UM #2, reviewed the first floor's medication storage room. The following was observed:
1. One expired 1000 milliliter (ml) bag of 0.9% sodium chloride (normal saline) intravenous (IV) solution with expiration date October 2023
2. One opened multi-dose vial of Novolog 100 units/ml insulin stored in the medication refrigerator labeled with an opened date of 10/16. The RN/UM2 confirmed this was opened and dated on 10/16/23 and is good for 28 days after opening and should have been discarded.
Further review of the February 2024 medication refrigerator temperature monitoring log indicated the following temperatures in degrees Fahrenheit (F):
2/1: 30
2/2: 30
2/3: 30
2/4: 30
2/5: 29
2/6: 30
2/7: 30
2/8: 31
2/9: 30
2/10: 30
2/11: 30
2/12: 30
2/13: 30
2/14: 30
2/16: 30
2/17: 30
2/18: 30
2/19: 30
2/20: 29
2/21: 32
2/22: 32
2/23: 32
2/24: 32
2/25: 30
2/26: 30
2/27: 30
On 02/28/2024 at 11:00 AM, in the presence of a second state surveyor and a federal surveyor, interviewed the Licensed Practical Nurse (LPN #4) who stated nurses assigned to the medication cart are responsible for the organization and cleanliness of the cart. She further stated there should be no loose pills in the drawers, and all medications should be labeled and dated once opened, including multi-dose medications such as vials and inhalers should be labeled and dated on the vial, bottle, or device containing the medication. At this point the surveyor, along with LPN #4, reviewed nursing unit 1A's medication cart 1A - back. The following was observed:
1. Eight (8) loose pills of various shapes, colors, and sizes.
2. One opened vial of Lantus 100 unit/ml insulin undated.
3. One Lispro U-100 insulin vial opened and undated.
4. One opened fluticasone propionate (nasal spray) 0.54 fluid ounce bottle undated
5. One gentamicin solution 0.3% ophthalmic (eye drops) opened and undated
6. One Incruse umeclidinium inhalation powder 62.5 microgram (mcg) (medication used to treat lung disease) inhaler opened and undated.
7. One budesonide and formoterol fumarate dihydrate inhalation aerosol 160/4.5 (medication used to treat lung disease) inhaler opened and not dated or labeled.
On 02/28/2024 at 11:41 AM, in the presence of a second state surveyor, the surveyor interviewed LPN #3, who confirmed that opened multi-dose medications should be labeled with resident's name and dated with opened date, and there should be no loose pills in the cart drawers. At this point the surveyor along with LPN #3 reviewed nursing unit 1C's medication cart. The following was observed:
1. Four (4) loose pills of various shapes, colors, and sizes.
2. One fluticasone propionate/salmeterol discus inhalation powder 100 mcg/50 mcg inhaler (medication to treat lung disease) opened and not dated.
3. One fluticasone propionate/salmeterol discus inhalation powder 500 mcg/50 mcg inhaler opened and not dated.
4. One budesonide and formoterol fumarate dihydrate inhalation aerosol 80 mcg/4.5 mcg inhaler opened and not dated or labeled.
5. One fluticasone propionate (nasal spray) 15.8 ml bottle opened and not dated or labeled.
6. One Systane solution (eye drops) bottle opened not labeled or dated.
7. One Systane solution bottle opened not dated.
8. One olopatadine hydrochloride ophthalmic solution 0.2% (eye drops) opened and not dated.
9. One carboxymethylcellulose sodium ophthalmic solution 0.5% (eye drops) opened bottle not dated.
Once the surveyor completed review of the medication cart, LPN #3 stated she would discard of the loose pills in the sharps container (a plastic container attached to the side of the medication cart, used to dispose of potentially sharp medical equipment). When the surveyor questioned that action, LPN #3 stated she was not sure where to discard and would ask the unit manager.
On 02/28/2024 at 12:29 PM, in the presence of a second state surveyor, the surveyor interviewed LPN #1, who also confirmed that medication containers and vials should be labeled and dated once opened. At this point the surveyor along with LPN #1 reviewed nursing unit 2A's medication cart. The following was observed:
1. One Anoro Ellipta inhalation powder inhaler (medication used to treat lung disease) opened and not dated.
2. One box of albuterol sulfate inhalation solution 0.083% 2.5 mg/ 3 ml (medication used to treat lung disease) which contained one opened and undated foil pouch containing 23 single use vials.
3. One Incurse Ellipta 62.5 mcg inhalation powder inhaler (medication used to treat lung disease) opened and not labeled or dated.
4. One Ventolin HFA 90 mcg inhaler (medication used to treat lung disease) opened and not labeled or dated.
On 02/28/2024 at 1:01 PM, in the presence of a second state surveyor, the surveyor interviewed LPN #2, who stated that there should be no loose pills in the carts and that opened multi-dose medications should be labeled and dated once opened. At this point the surveyor along with LPN #2 reviewed nursing unit 2D's medication cart. The following was observed:
1. 15 loose pills of various colors, shapes, and sizes.
2. One fluticasone propionate (nasal spray) opened and not dated.
3. One box of ipratropium bromide 0.5 mg and albuterol sulfate 3 mg (medication used to treat lung disease) containing one opened and undated foil pouch with four single dose vials.
On 02/28/2024 at 01:55 PM, the surveyor, in the presence of a second state surveyor, interviewed the Director of Nursing (DON) who stated, that expired medications should be removed immediately from medication storage areas, medication refrigerator temperatures should be maintained between 34- and 46-degrees F and that temperatures outside the acceptable range could compromise the efficacy of the medication and could have negative effects for residents. The DON further stated that opened medication bottles should not be stored in the medication storage rooms, once opened, multi-use medications, whether inhalers, insulin, or otherwise, should be labeled and dated with the date opened and preferably the resident's name, stored appropriately, and discarded after 30 days of opening. Furthermore, the DON included that medications should always be disposed of appropriately in the drug buster bottle and not in the sharps container.
On 02/29/2024 at 12:30 PM, the surveyor, in the presence of a federal surveyor, interviewed the facility's pharmacy consultant pharmacist (RPh) by telephone, who stated multi-dose medications are good for 30 days after opening unless it is insulin, which expires 28 days after opening. The RPh stated the insulin vial dated as being opened 10/16 should have been discarded. She further confirmed that best practice would be to label and date the medication device, bottle, inhaler, or vial itself once opened with the resident's name and date opened in case the medication and its box were to be separated. She stated refrigerated medications should be stored between 36- and 46-degrees F, and if not could affect the medication's potency. She stated medication refrigerator temperatures should be checked at least once a day to maintain appropriate temperature storage. She further included that medications should not be disposed of in the sharps container or flushed, rather in the medication drug buster or biohazard waste container, depending on the medication.
b.) On 02/29/2024 at 2:14 PM, the surveyor observed LPN #2 on the second-floor nursing unit 2D prepare a wound care treatment cart for use by the nurses' station. She had the cart unlocked when she was approached by a resident in a wheelchair. LPN2 then walked away from the treatment cart to assist the resident back to their room, leaving the cart unlocked. The surveyor observed the unlocked cart and other nursing staff members walk past the unlocked cart a total of six times without acknowledging the cart not being secured. The surveyor did not observe any residents come near the treatment cart during this time, however there were seven residents around the nursing station in geriatric chairs and wheelchairs.
At 2:24 PM, once LPN #2 returned to the treatment cart, the surveyor asked about the unlocked cart, to which the LPN #2 acknowledged it was left unlocked stating, I know its unlocked, I don't have a key for it that's why I left it. LPN #2 confirmed there were medications stored in the cart and should not have left it unlocked unattended.
On 02/29/2024 at 2:35 PM, the surveyor, in the presence of a federal surveyor, observed LPN #2 preparing wound care supplies from the treatment cart by a resident's room in the 2D nursing unit hallway. LPN #2 walked away from the treatment cart to obtain gloves from the glove dispenser on the wall and perform hand hygiene with alcohol based hand sanitizer, leaving the treatment cart unlocked.
On 03/01/2024 at 1:41 PM, the surveyor, in the presence of a federal surveyor, interviewed the Director of Nursing (DON), who stated the expectation is for medication and treatment carts are to be locked when not attended by the nursing staff. She stated treatment carts contain medications for wound and other care and leaving them unlocked could risk residents being able to access their contents.
A review of the facility's Medication Storage policy with a last revised date of 12/2023, under the section titled policy, included but was not limited to, to provide guidelines for proper storage of medications within the facility. this center will have medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with department of health guidelines. The section titled procedure included, medications will be stored in an orderly, organized manner in a clean area . medications will be stored in the original labeled containers received from the pharmacy. Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. Medication requiring refrigeration will be stored in a refrigerator that is maintained between 2 to 8 degrees Celsius (36 to 46 degrees F) . temperature will be checked daily to ensure it is within the specified range. If temperature is out of range, the refrigerator thermostat will be adjusted.
A review of the facility's Medication Administration policy with revised date 12/2023, included but was not limited to, the expiration date on the medication label must be checked prior to administering. When opening a multi-dose container, the date shall be recorded on the container . during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide . the cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.
A review of the facility's Multi-Dose Vials policy with revised date 12/2022 included but was not limited to, if a multi-dose vial has been opened or accessed (e.g., needle punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter) date .
Review of the facility's Narcotic Destruction policy with revised date 9/2023, included but was not limited to, soiled, damaged, expired drugs, discontinued controlled drugs, oral solid medications, and liquids can be destroyed using drug buster/RX Destroyer disposal system.
N.J.A.C. 8:39-29.4
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and cons...
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Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:
Repeat deficiency from recertification survey of 09/20/2022
On 02/27/2024 from 9:32 AM to 10:21 AM, the surveyors, accompanied the Director of Food Services (DOFS), observed the following in the kitchen:
The surveyors observed a dietary aide (DA) in the kitchen. The DA had lengthy braids to mid shoulder and was observed wearing a baseball style hat. The braids extended past the shoulders and were exposed. The DA did not have a hair net in place and the hair was exposed.
In the dry storage room, a can of corn on the 4 wheeled mobile can rack had a significant dent and a can of artichokes on a shelf had a significant dent on the seam. On interview the DOFS agreed that the cans should have been placed in the designated dented can area,
In the dessert and juice refrigerator the surveyors observed (5) trays of portioned controlled, in house poured juices designated for resident use. The juices had no dates. The DOFS was asked if they should be labeled according to facility policy. The DOFS replied, Yes.
In the walk-in freezer the surveyors observed (3) bags of unopened cauliflower and 1 bag of unopened yellow squash that had been removed from their original container. The cauliflower and squash had no dates.
In the walk-in refrigerator the surveyors observed (7) bags of unopened lettuce on various shelves with a manufacturer's best if used by date of 2/22/24. The DOFS stated, We just got them in, they must have come in that way. When asked who was responsible for checking the food in, the DOFS stated, We are.
In the prep refrigerator, the surveyors observed an unopened bag of lettuce with a best if used by date of 2/22/24, and an unopened bag of tortillas labeled received 2/1 and use by 2/18/24.
The surveyors observed (2) air conditioners in the food prep area near the tray line. A finger swipe by the surveyor determined that the vents of the air conditioners were covered with a black, dust-like substance. When asked when they were last cleaned the DOFS replied, Every two weeks, it is on the cleaning schedule, and we haven't turned it on in two months.
On 02/29/2024 from 10:56 AM to 11:28 AM, the surveyors, accompanied by the DOFS, observed the following during a follow up visit to the kitchen: In the walk-in refrigerator the surveyors observed approximately 6-7 stacks of plastic crates which contained juices and milk. The 6-7 bottom crates were stored directly on the floor of the refrigerator and did meet the 6-inch requirement for food to be stored off the floor.
The surveyors observed the electrical outlet box behind the coffee machine and adjacent to the counter of the hot food holding/prep area. The box was covered in unidentified brown/grease-like debris. The backsplash of the coffee station was also covered in brown unidentified debris, as well as the water supply line.
At 11:06 AM, the surveyor observed a kitchen staff at the designated handwashing sink. Upon completion of hand-hygiene the staff attempted to grab a hand towel, however, the hand towel dispenser was empty. The staff walked to the dish washing room to obtain a hand towel at the designated hand washing sink. The hand towel dispenser was also empty. When asked who was responsible for ensuring that hand towels were sufficiently stocked, staff stated that the housekeeping department was responsible for stocking the hand towel dispensers.
On 03/04/2024 at 01:49 PM, during an interview with the surveyor, the Licensed Nursing Home Administrator agreed, all foods should be labeled, there should be no expired food in kitchen, and hair nets should be worn to encompass all the hair.
A review of facility provided policy titled USE BY DATE POLICY, last reviewed on 2/6/2023 revealed under POLICY:
All food items that are thawed, prepared or removed from their original container will have an expiration date or use by date: To ensure the freshness of all items being served; To provide a universal system of identification of expiration dates.
It was also revealed under PROCEDURE: 2. All kitchen staff will be in serviced on labeling procedures and 4. All items sent to floors and taken out of original containers, will have an expiration/ use by date.
A review of the facility provided policy titled PERSONAL HYGIENE POLICY, last revised on 01/2023 revealed the following under POLICY: All employees are required to follow acceptable personal hygiene practices to ensure that food is prepared, stored, and distributed in safe and sanitary manner, preventing the spread of food borne illness. It was also revealed under the heading PROCEDURE:
4. Employees must wear hair nets and beard restraint required by local and federal health codes. No hair ornaments are permitted unless function as hair restraint.
The surveyor reviewed the facility policy titled Food Safety-Food Handling Policy; last date revised: 09/2021. The following was revealed under the heading POLICY:
Food will be stored prepared, handled and served so that the risk of foodborne illness is minimized.
The following was revealed under the heading PROCEDURE: 7. All kitchen staff will be in serviced on labeling procedures. All prepared items stored in cooling units will be labeled and dated.A review of an undated facility provided kitchen cleaning schedule titled Nutrition Services Cleaning Responsibilities and Schedule did not reveal any Cleaning Duty for the (2) air conditioners. A Cleaning Duty for the Tea and Coffee Machine revealed it was to be cleaned daily by the AM aide.
N.J.A.C. 18:39-17.2(g)
Nov 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00165456
Based on interview, medical record review, and review of other pertinent facility documentation on 10/20...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00165456
Based on interview, medical record review, and review of other pertinent facility documentation on 10/20/23, 10/24/23, and 10/26/23, it was determined that the facility failed to develop a baseline care plan for a newly admitted resident who experienced pain. This deficient practice was identified for Resident #2, 1 of 2 residents reviewed for baseline care plans and was evidenced by the following:
The surveyor reviewed the closed medical record for Resident #2:
According to the admission Record, Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included but were not limited to cerebral infarction (disrupted blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move one side of the body) following cerebral infarction, cognitive communication deficit, opioid abuse, cocaine abuse, and muscle wasting and atrophy (decrease in size).
Review of the Discharge Return Anticipated Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/01/23 indicated that Resident #2 had short-term memory problems. The MDS also indicated the resident received scheduled and as needed pain medication while at the facility.
Review of the Order Recap Report (ORR) revealed a 05/25/23 physician's order (PO) for Buprenorphine HCl (a narcotic medication that can treat pain as well as addiction to narcotic pain relievers) 2 milligrams (mg) and to administer two tablets for a total of four milligrams, two times a day for induction (transfer the person from an abused opioid to a dose of Buprenorphine).
The ORR revealed a 05/25/23 PO for pain evaluation every shift to record pain on a 0-10 scale.
The ORR revealed a 05/25/23 PO order for Acetaminophen Tablet 325 mg and to administer two tablets by mouth every six hours as needed for pain.
Review of the May 2023 Medication Administration Record (MAR) revealed that that Resident #2 received Buprenorphine HCL 2 mg twice daily from 05/26/23- 05/31/23.
The May 2023 MAR revealed that Resident #3 had 8 out of 10 pain recorded on 05/28/23 on the 3 PM-11 PM shift and 7 out of 10 pain recorded on 05/30/23 on the 7 AM- 3 PM shift.
The May 2023 MAR also revealed that Resident #2 received two 325 mg Acetaminophen Tablets by mouth on 05/30/23 for pain that was rated an intensity of 9 out of 10.
Review of the June 2023 MAR revealed that Resident #2 received Buprenorphine HCl 2 mg in the morning on 06/01/23.
Review of the 05/31/23 Physician Progress Note (PPN) revealed that Resident #2 was in significant pain and would not tolerate positioning for wound evaluation. Resident #2 was medicated for pain and was referred to their primary care physician to evaluate the pain.
Review of the 06/01/23 PPN revealed that Resident #2 was noted with left leg pain and pain to their left leg with attempts to perform passive range of motion (range of motion that is achieved when an outside force exclusively causes movement of a joint).
Review of Resident #2's baseline care plan did not address Resident #2's pain.
During an interview with the surveyor on 10/26/23 at 11:10 AM, the Licensed Practical Nurse/Unit Manager (LPN/UM) stated that Resident #2 should have had a baseline care plan in place for alteration in comfort because the resident had pain. The LPN/UM continued that all residents were at risk for pain while they stayed at the facility and therefore should have a care plan in place to address it.
During an interview with the surveyor on 10/26/23 at 12:37 PM, the Director of Nursing (DON) stated the purpose of the baseline care plan was to capture and encompass all parts of the resident's plan of care. The DON continued that Resident #2 had a history of substance abuse and took Buprenorphine. The DON stated that pain should have addressed in the care plan because they were at risk for an alteration in comfort at the facility.
Review of the facility policy, Care Plans-Baseline with a revised date of 01/20, indicated under the Policy section that, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. The facility policy continued under the Procedure section that, The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; Social services; and f. PASARR [a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes] recommendations, if applicable.
NJAC 8:39-11.2(d).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00168282, NJ00168313
Based on observation, interview, review of medical records, and review of other pertinent fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00168282, NJ00168313
Based on observation, interview, review of medical records, and review of other pertinent facility documentation on [DATE], [DATE], and [DATE], it was determined that the facility failed to update a comprehensive care plan for a resident who had a life-threatening event. The deficient practice was identified for Resident #3, 1 of 4 residents reviewed for comprehensive care plans and was evidenced by the following:
During an interview with the surveyor on [DATE] at 12:23 PM, Resident #3 stated that they overdosed on fentanyl (a synthetic opioid) twice at the facility within the last few months. The resident stated that facility staff used Narcan (opioid overdose treatment) on him/her and that they were sent out to the hospital after each overdose.
According to the admission Record, Resident #3 was readmitted to the facility on [DATE] with medical diagnoses that included but were not limited to poisoning by other drugs, medicaments (substance used as medicine) and biological substances, accidental, opioid dependence, and chronic pain syndrome.
Review of the [DATE] Minimum Data Set (MDS), an assessment tool used to facilitate the management of care revealed a Brief Interview for Mental Status score of 15 which indicated that the resident was cognitively intact. The MDS also indicated the resident had occasional moderate pain and that they took an opioid while at the facility.
Review of the General Progress Note (PN) dated [DATE] revealed that the nurse found Resident #3 unresponsive, gasping for breath, and with their eyes rolled back in their head. The resident's pulse was faint. The nurse administered Narcan into the resident's nose three times and once into the resident's muscle. The resident was noted to be blue and the nurse directed the certified nursing assistant to call a code blue (cardiac or respiratory arrest). The nurse was unable to obtain the resident's blood pressure and started CPR (cardiopulmonary resuscitation; an emergency lifesaving procedure performed when the heart stops beating) on the resident. After the fourth dose of Narcan the resident became responsive. The emergency medical technicians arrived, and Resident #3 was transported to the hospital.
Review of the substance abuse care plan initiated [DATE] revealed the following interventions:
Psychiatry and psychology consult Date initiated: [DATE]. Created on: [DATE].
Staff education regarding s/s [signs/symptoms] of overdose and administration of Narcan. Date initiated: [DATE]. Created on: [DATE].
Review of the Nursing Clinical Evaluation PN dated [DATE] indicated that Resident #3 had a drug overdose. The PN continued that staff were called to the resident's room by a staff member who stated that the resident was not breathing. Resident #3 was found on their bed, with purple/ blue skin and was unresponsive to verbal commands or touch. Resident #3 was administered two doses of Narcan, nasally, and one dose intramuscularly. The resident became responsive and was sent to the emergency room for evaluation.
During an interview with the surveyor on [DATE] at 1:17 PM, the Director of Nursing (DON) stated that Resident #3's care plan was updated to coincide with the incident dates of the overdoses. The DON continued that the updated interventions were put in place on [DATE]. The DON added that the care plan was updated to reflect the new interventions when she reviewed the incident report.
During an interview with the surveyor on [DATE] at 09:53 AM, Certified Nursing Assistant (CNA) #1 stated that after Resident #3's [DATE] overdose, he/she was no longer allowed to have other residents visit their room. He/she had to have visitation in the day room. CNA #1 stated that staff were re-educated immediately after the first overdose happened.
During an interview with the surveyor on [DATE] at 10:12 AM, Licensed Practical Nurse (LPN) #1 stated that after the resident's [DATE] overdose, she talked to Resident #3 and took an inventory of his/her things. LPN #1 continued that the resident consented to a search and that some contraband items were removed from their room. LPN #1 stated they also asked for other residents to stop visiting Resident #3's room. The LPN continued that Resident #3 and the staff received education the day after the overdose occurred.
During a follow-up interview with the surveyor on [DATE] at 12:37 PM, the DON stated the purpose of updating a care plan in a timely manner was to make sure that all the interventions were put into place for the resident. The DON continued that all the interventions were put into place immediately after Resident #3's [DATE] overdose. The DON stated that interventions included reeducation of the nurses, having the resident's narcotics put on hold for 72 hours, and having the nurse's crush the resident's narcotics. The DON continued that there was no Unit Manager, so the care plan was not updated until she went through the investigation and updated it herself.
Review of the facility policy, Care Plans- Comprehensive, with a revised date of 10/2019 indicated under the Procedure section that The comprehensive, person-centered care plan will: [ .] Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; [ .] Incorporate identified problem areas; The facility policy continued, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. [ .] The Interdisciplinary Team reviews and updates the care plan: [ .] When the resident has been readmitted to the facility from a hospital stay.
NJAC 8:39-11.2(e)(f)(i).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00165456
Based on interview, medical record review, and review of other pertinent facility documentation on 10/20...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #: NJ00165456
Based on interview, medical record review, and review of other pertinent facility documentation on 10/20/23, 10/24/23, and 10/26/23, it was determined that the facility failed to provide treatment for a resident with a pressure ulcer. The deficient practice was identified for Resident #2, 1 of 2 residents reviewed for pressure ulcers and was evidenced by the following:
The surveyor reviewed the closed medical record for Resident #2:
Review of the admission Record revealed that Resident #2 was admitted to the facility on [DATE] with medical diagnoses which included but were not limited to cerebral infarction (disrupted blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move one side of the body) following cerebral infarction, cognitive communication deficit, and muscle wasting and atrophy (decrease in size).
Review of the Discharge Return Anticipated Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/01/23, indicated that Resident #2 had short-term memory problems. The MDS also indicated that the resident had one Stage 3 pressure ulcer (injury to the skin and underlying tissue caused by sustained pressure that extends through the skin into deeper tissue and fat) that was present upon admission to the facility.
Review of the Admission/ readmission Evaluation dated 05/25/23 indicated that Resident #2 was admitted to the facility with a pressure ulcer on their coccyx (tailbone) which measured 4 centimeters (cm) long, 4.5 cm wide, and 0 centimeters deep. The evaluation also indicated that the wound was 25% covered in slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous).
Review of Resident #2's skin integrity care plan initiated on 05/25/23 revealed that the resident had an actual pressure injury to their sacrum (large, flat, triangular-shaped bone between the hip bones).
Review of the Admission/ readmission Evaluation, dated 05/30/23, revealed that Resident #2 was assessed on the Braden Scale (a tool to measure the risk of pressure ulcer development) as moderate risk for pressure ulcer development.
Review of the 06/01/23 Physician Progress Note indicated that Resident #1 had a sacral wound and had Santyl (an ointment used to help the healing of skin ulcers) ordered to the area.
Review of the Order Recap Report (ORR) revealed a 06/01/23 Physician's Order (PO) for Santyl External Ointment 250 unit per gram to Resident #2's sacrum topically one time a day. The PO specified to clean the wound with normal saline solution, apply Santyl, and to cover it with a conventional dry dressing.
The ORR did not reveal a PO for wound care treatment from 05/25/23-06/01/23.
Review of Resident #2's May 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to reveal documentation that any wound care treatment was provided to Resident #2's pressure ulcer.
Review of Resident #2's June 2023 MAR revealed a 06/01/23 Physician's Order (PO) for Santyl External Ointment 250 unit per gram to Resident #2's sacrum topically one time a day. The PO specified to clean the wound with normal saline solution, apply Santyl, and to cover it with a conventional dry dressing.
During an interview with the surveyor on 10/20/23 at 2:32 PM, Licensed Practical Nurse (LPN) #1 stated that she remembered and took care of Resident #2. LPN #1 stated that Resident #2 had a wound on their sacrum but that she did not remember the wound care treatment ordered for the wound. LPN #1 continued that when a resident came in with a wound that it was recognized on the admission evaluation's skin assessment. LPN #1 stated the nurse would notify the nursing supervisor and document about the wound. LPN #1 added that the nurse would call the doctor to initiate a wound care treatment for the wound.
During an interview with the surveyor on 10/24/23 at 11:03 AM, the LPN/ Assistant Director of Nursing (ADON) stated the assigned nurse would do an initial skin assessment upon admission to the facility. The LPN/ADON continued that the nurse would obtain wound care treatment orders from the resident's doctor. The LPN/ADON stated that the purpose of timely wound care treatment was to ensure that the wound did not get worse and to promote wound healing. The nurse completing the admission should have contacted the doctor and obtained a wound care treatment order for Resident #2. The LPN/ADON added that she was not sure why a wound care treatment order was not obtained for the resident.
During an interview with the surveyor on 10/24/23 at 12:11 PM, the LPN/ Unit Manager (UM) stated that the nurse would complete a skin assessment when a resident was admitted . The LPN/UM continued that the nurse would document their findings, update the resident's care plan, notify the doctor of the wound, and confirm that they had an order for treatment. The LPN/UM continued that newly admitted residents had two nursing skin assessments performed during their first 48 hours in the facility. The LPN/UM stated that an order for a wound treatment should have been obtained on the same day the resident was admitted . The LPN/UM continued that it was important to make sure that wound care treatment orders were initiated timely so the wound could be taken care of in a timely manner. The LPN/UM stated that she did not know how Resident #2's wound care treatment orders were missed.
During an interview with the surveyor on 10/24/23 at 1:17 PM, the Director of Nursing (DON) stated the nurse would complete the admission skin assessment. The DON continued that the ADON would complete the second day skin assessment. The DON stated that the ADON was responsible to make sure that the assessment was accurate and included the wound's measurement and stage, that a care plan was in place, and that a wound care treatment was ordered. The DON stated that the ADON did not follow the wound process for Resident #2. The DON further stated, you don't have someone with a wound and don't put a treatment [order] in. The DON continued that the purpose of timely initiation of wound care treatment and interventions was to restore the resident's health and to prevent the wound from getting worse.
During an interview with the surveyor on 10/27/23 at 1:10 PM, the LPN/ House Supervisor stated that whenever an admission skin assessment was done, and a wound was identified, she would call the doctor to obtain a wound care treatment order. The LPN/ House Supervisor stated she did not remember completing Resident #2's admission and did not know why the doctor was not called for a wound care treatment order.
Review of the facility policy, Wound Identification and Wound Rounds with a revised date of 12/21 indicated under the New admission section, 1. All new admissions will have a complete body check on admission to identify any open areas [ .] 3. Open areas identified on admission a. On admission, the licensed nurse completed a head-to-toe skin evaluation for the presence of skin impairments. B. Upon discovery of a skin impairment, the Registered Nurse (RN) completes a skin assessment, including documentation of size, depth, stage and appearance of the skin impairment. C. The physician should be notified to obtain appropriate treatment utilizing the Centers Wound Care Guideline. The licensed Nurse will notify the physician and obtain a treatment order utilizing the Centers Wound Care Guidelines. E. The RN should initiate a care plan including prevention interventions as necessary [ .].
Review of the undated Job Description for Assistant Director of Nurses indicated under the Nature and Scope section that, The Assistant Director of Nursing Services may confer with residents' physicians on an occasional basis to clarify medical orders and direct care. The Job Description continued under the Principal Job Accountabilities section, that the ADON is responsible to, Ensure that medical and nursing care is administered in accordance with the resident's wishes and per the individualized care plan.
NJAC 8:39-27.1(e).
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00164862, NJ00165456, NJ00168282, NJ00168313, NJ00168836
Based on observation, interview, medical record review, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint # NJ00164862, NJ00165456, NJ00168282, NJ00168313, NJ00168836
Based on observation, interview, medical record review, and review of other pertinent facility documentation on 10/20/23, 10/24/23, 10/26/23, and 11/09/23 it was determined that facility staff failed to consistently document on the Documentation Survey Report, the Activities of Daily Living (ADL) status and care provided to the residents. In addition, the facility staff failed to follow the facility's policy titled Charting and Documentation-CNA for Resident #1, #2, #3, and #5, 4 of 5 residents reviewed for documentation.
The deficient practice was evidenced by the following:
1. According to the admission Record (AR), Resident #1 was admitted to the facility on [DATE] with medical diagnoses that included but were not limited to chronic obstructive pulmonary disease (COPD) (a group of diseases that case airflow blockage and breathing-related problems), dysphagia (difficulty swallowing), hearing loss, bilateral (both sides), anxiety disorder, and major depressive disorder.
Review of the quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/26/23, indicated that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated that the resident was cognitively intact. The MDS also indicated that Resident #1 required supervision assistance from staff to use the bathroom and that they were frequently incontinent of urine and bowel.
The care plan initiated on 10/07/21 indicated focuses on bladder incontinence and ADLs. The ADL care plan included an intervention that Resident #1 required supervision assistance from staff to use the toilet and that the resident should be toileted prior to be being put to bed on all shifts.
The surveyor reviewed the Documentation Survey Report (DSR), an ADL record documented by the Certified Nursing Assistants (CNA) during their assigned shifts for June, September, and October 2023. The DSR forms had assigned ADL care tasks which included but were not limited to bladder/ bowel continence and toilet use.
Review of Resident #1's ADL record included an area for the CNAs to document the resident's self-performance and the support provided by staff. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts:
Day shift on 06/11/23, 06/25/23, 09/08/23.
Evening shift on 06/25/23, 06/03/23, 09/03/23, 09/10/23, 09/12/23, 09/18/23, 09/24/23, 09/28/23.
Night shifts on 06/03/23, 06/19/23, 06/26/23, 09/05/23, 09/10/23, 09/17/23, 10/01/23, 10/12/23, 10/16/23, 10/20/23.
2. According to the AR, Resident #3 was readmitted to the facility on [DATE] with medical diagnoses that included but were not limited to poisoning by other drugs, medicaments (substances used as medicine) and biological substances, accidental, opioid (pain relieving drug) dependence, and chronic pain syndrome.
Review of the 08/15/23 MDS revealed a BIMS score of 15 which indicated that the resident was cognitively intact. The MDS also indicated that the resident had occasional moderate pain and that they took an opioid while in the facility.
Review of the substance abuse care plan initiated on 11/04/19 revealed an intervention for frequent monitoring for substance abuse by the CNAs and to notify the nurse if any signs were noted.
The surveyor reviewed the DSR during the CNA's assigned shifts for September and October 2023. The DSR forms had assigned ADL care tasks which included but were not limited to frequent monitoring for substance abuse: monitor resident for increased lethargy, pale clammy skin, limp extremities, vomiting or gurgling, purple or blue lips and fingernails, slurred speech, unable to speak, slow breathing or heart rate. If any of these symptoms are present, notify the nurse immediately.
Review of Resident #3's ADL record included an area for the CNAs to document the resident's self-performance and the support provided by staff. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts:
Day shift: 09/03/23, 09/08/23, 09/10/23, 09/11/23, 09/21/23, 09/22/23, 10/09/23, 10/12/23, 10/14/23.
Evening shift: 09/03/23, 09/05/23, 09/08/23, 09/10/23, 09/14/23, 09/19/23, 09/24/23, 10/02/23, 10/16/23.
Night shift: 09/24/23, 10/02/23, 10/09/23, 10/15/23.
3. The surveyor reviewed the closed medical record for Resident #2:
According to the AR, Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included but were not limited to cerebral infarction (disrupted blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move one side of the body) following cerebral infarction, cognitive communication deficit, and muscle wasting and atrophy (decrease in size).
Review of the Discharge Return Anticipated MDS, dated [DATE] indicated that Resident #2 had short-term memory problems. The MDS also indicated that the resident required extensive assistance with toilet use and was frequently incontinent of urine and bowel.
Review of the care plan initiated on 06/01/23 indicated that Resident #2 required assistance with ADLs.
The surveyor reviewed the DSR during the CNA's assigned shifts for May and June 2023. The DSR forms had assigned ADL care tasks which included but were not limited to bladder/bowel continence.
Review of Resident #2's ADL record included an area for the CNAs to document the Resident's self-performance and the support provided by staff. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts:
Day shift: 05/25/23, 05/28/23, and 06/01/23.
Night shift: 06/30/23.
4. According to the AR, Resident #5 was admitted to the facility on [DATE] with medical diagnoses that included but were not limited to psychoactive substance abuse, paraplegia (paralysis of the legs and lower body), and seizures.
Review of the admission MDS, dated [DATE] indicated that Resident #5 had a BIMS score of 13 which indicated the resident had intact cognition.
Review of the substance abuse care plan initiated 10/29/23 revealed an intervention for frequent monitoring for substance abuse by the CNAs and to notify the nurse if any signs were noted.
The surveyor reviewed the DSR during the CNA's assigned shifts for October and November 2023. The DSR forms had assigned ADL care tasks which included but were not limited to frequent monitoring for substance abuse: monitor resident for increased lethargy, pale clammy skin, limp extremities, vomiting or gurgling, purple or blue lips and fingernails, slurred speech, unable to speak, slow breathing or heart rate. If any of these symptoms are present, notify the nurse immediately.
Review of Resident #5's ADL record included an area for the CNAs to document the resident's self-performance and the support provided by staff. There was no documentation completed for the aforementioned ADL care tasks for the following dates and shifts:
Day shift: 11/03/23, 11/07/23.
Night shift: 10/30/23, 10/31/23, 11/03/23, 11/06/23.
During an interview with the surveyor on 10/26/23 at 9:38 AM, CNA #1 stated that she was able to provide high quality ADL care, including incontinence care, for all her assigned residents, including Resident #1. CNA #1 stated that ADL care should be documented every shift for every resident. CNA #1 continued that the purpose of the documentation was to prove that the care was provided.
During an interview with the surveyor on 10/26/23 at 10:12 AM, Licensed Practical Nurse (LPN) #1 stated that CNAs should document the ADL care and monitoring that they provide every shift. LPN #1 continued that the CNAs were responsible to complete the documentation but that the nurses should check and ensure that the documentation was completed.
During an interview with the surveyor on 10/26/23 at 12:37 PM, the Director of Nursing (DON) stated that ADL care should be documented every shift. The DON stated the purpose of ADL care documentation was to substantiate that the care was provided.
Review of the facility policy, Charting and Documentation- CNA dated 03/20 indicated under the Procedure section, Certified Nursing Assistants may make entries in the resident's medical chart all care rendered to residents [ .]. Monitoring of residents shall also be documented as described in the C.N.A. care cards/tasks.
NJAC 8:39-35.2 (d)(6).
Jun 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #'s : NJ00159849, NJ00163909
Based on observations and interviews, the facility failed to ensure sufficient staffing t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #'s : NJ00159849, NJ00163909
Based on observations and interviews, the facility failed to ensure sufficient staffing to meet the needs of 138 residents in the facility. One resident (Resident (R) 2) and staff members (Licensed Practical Nurse 1, LPN2, and LPN3), Certified Nurse Aides (CNA2 and CNA3), and Housekeeper 1 voiced concerns regarding sufficient staffing.
Findings include:
Review of R2's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R2 was admitted to the facility on [DATE] with diagnoses including chronic pain and falls.
Review of R2's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/23, revealed R2 scored a 15 out of 15 on the Brief Interview for Mental Status, which indicated R2 was cognitively intact.
During an interview on 06/11/23 at 10:48 am, R2 stated he experienced long wait times for care to be delivered. R2 stated he had to wait lengthy periods of time for assistance with toileting and pain medications. R2 stated this usually occurred on the weekends and at night.
On 06/13/23 at 9:30 AM, staffing schedules were reviewed with the Director of Nursing (DON). The DON stated she was aware that additional staff were needed. She stated the facility was always recruiting and hiring support staff such as CNAs and housekeeping staff, but the geographical area had many long term care/healthcare facilities that were competing for a limited number of CNAs in the area, so the turn-over rate was very high. The DON stated that the facility did use agency staff as a last resort, but they preferred to provide incentives for their own employees for quality, consistent care.
Random CNAs and Licensed Practical Nurses and Registered Nurses were asked about their staffing and workloads. CNAs 1 and 2 stated there were days when there were not enough CNAs to get everything done. CNA 1 stated she missed the time when they could socially interact with the residents, but now verbal interaction only occurred during toileting or dressing.
In an interview on 06/14/23 at 2:30 PM with the Nurse Practitioner, the DON, the Administrator, and the Regional Nurse, the staff members stated that the population in the facility was younger to middle aged residents who had cognitive deficits, behaviors, and dementia or psychiatric illnesses. All concurred that the resident acuity required additional staff for increased supervision and to reduce opportunities for behavioral concerns in the facility.
Multiple staff interviews were conducted with CNAs2 and 3, as well as with LPNs 1, 2, and 3. The staff worked both shifts and all halls. The staff interviews revealed that the staff felt their assignments were usually manageable, but if one person did not show up for work, then staffing for the entire shift was ruined.
During an interview on 06/11/23 at 2:10 PM, Housekeeper 1 stated that if one person did not show up for work, she had to clean the whole building. Housekeeper 1 stated that could not be done. Housekeeper 1 stated that did not happen very often, but it did happen.
The DON and Administrator were interviewed on 06/14/23 at 10:15 AM. The DON stated they did supplement their staff with agency nurses and CNAs when they had to, but they preferred to offer incentives to their own employees. Both stated their staffing had improved and they were still hiring for all positions.,. A facility policy was requested related to adequate staffing, and the DON stated she did not think they had a policy that addressed that specifically, but her expectation was always to have enough staff to meet the residents needs on all shifts, including the weekends.
NJAC :8:39-5.1 (a)
Nov 2022
4 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0808
(Tag F0808)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ159249
Based on interviews, medical records review, and review of other pertinent facility documentation on 11/3/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ159249
Based on interviews, medical records review, and review of other pertinent facility documentation on 11/3/2022 and 11/7/2022, it was determined that the facility failed to provide the correct Therapeutic Diet to a resident (Resident #2), a cognitively impaired Resident with a known diagnosis of Oropharyngeal Phase Dysphagia (difficulty swallowing), Unspecified Cerebral Infarction and Hemiplegia, and Hemiparesis following Cerebral Infarction, who had a Physician's Order and Plan of Care for a regular diet pureed texture, and Nectar Thick consistency, on 10/25/2022 at approximately 4:30 a.m.
According to the Certified Nursing Assistant (CNA #1), Resident #2 asked her for a sandwich, she stated asked the Licensed Practice Nurse (LPN #1) if Resident #2 could have a sandwich, and the LPN said yes. She then gave Resident #2 a whole tuna fish sandwich, which the Resident ate, and she disposed of the rest.
According to CNA #2, on 10/25/2022 at approximately 7:15 a.m., she went into Resident #2's room and observed that the head of the bed was completely flat; she thought the Resident was awake, so she talked to him/her, and there was no response, so she touched Resident #2, and the Resident was ice cold. She immediately notified the Charge Nurse Licensed Practice Nurse (LPN #2), a code blue was called at 7:20 a.m., and all staff came to assist. LPN #2 and LPN #3 responded to the code and initiated Cardiopulmonary Resuscitation (CPR). A giant, hard cookie flew off the blanket when Paramedics arrived and pulled the sheets off of Resident #2.
According to LPN #2, Resident #2 was lying flat with his/her mouth open with food in the mouth, and she saw a half-eaten sandwich and cookies in the bed with Resident #2. When Resident #2 was turned to put the board under him/her, food was in bed, and the Resident's mouth was open and smelled like peanut butter. Resident #2 death was then pronounced by the Director of Nursing (DON).
The facility failed to follow its policies titled Therapeutic Diet Policy, Comprehensive Care Plan, Physician Orders, a company Diet Manual, and the International Dysphagia Diet Standardization Initiative (IDDSI).
The facility's failure to provide the correct therapeutic Diet placed Resident #2 and all other residents on a therapeutic diet at risk for an Immediate Jeopardy (IJ) situation. This IJ was identified and reported to the facility's Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) on 11/3/2022 at 5:35 p.m. The Administrator was presented with the IJ template that included information about the issue. The IJ began on 10/25/2022 and continued through 11/4/2022 when CNA #1 was educated and all staff on the correct snacks to provide residents with a pureed diet.
On 11/7/2022, the Surveyors did a revisit to verify the Removal Plan was implemented. The facility implemented the Removal Plan, which included educating CNA #1 and all facility staff on the diet manual, the diet book, and how to obtain a correct therapeutic diet for residents and the correct snacks to be served to residents on a pureed diet. So the noncompliance remained on 11/7/2022 as a level D for no actual harm with potential for more than minimal harm that is not immediate jeopardy, based on the following: all staff were educated on residents on a therapeutic diet and the correct snacks to be given on a pureed diet.
This deficient practice was identified for 1 of 3 residents (Resident #2) and was evidenced by the following:
According to the admission Record (AR), Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Oropharyngeal Phase Dysphagia, Unspecified Cerebral Infarction, and Hemiplegia and Hemiparesis following Cerebral Infarction.
According to the Minimum Data Set (MDS), an assessment tool dated 10/01/2022, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 3/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #2 needed extensive assistance with most Activities of Daily Living (ADLs) and was total dependence on staff for eating.
A review of the Resident's Care Plan (CP) initiated on 06/24/2021 revealed under Focus: Nutrition problem: r/t (related/to) moderate malnutrition, mech (mechanical) altered diet, dysphagia, significant weight loss x 1 mos (month), decreased PO (by mouth) intake. The CP also included under Goal: Resident will be adequately nourished and hydrated via intake from meals and fluids through the review date. Also, under Interventions: included, .Provide regular Diet and puree nectar/mildly thick liquids consistency per MD (Physician) order .
A review of Resident #2's Order Summary Report (OSR) dated Active Orders as of 10/25/2022 under Dietary-Diet revealed under Order Summary Regular diet Puree texture, Nectar Thick/Mildly Thick consistency for diet dated 4/21/2022.
A review of Resident #2's Progress Notes (PNs) revealed the following:
On 10/25/2022 at 8:26 a.m., the PNs written by the DON revealed Registered Nurse (RN) Assessment called to [the] Resident room. Resident (Resident #2) [was] not breathing and was unresponsive at approximately 0720 (7:20 a.m.). No respirations, apical pulse, or heart/breath sounds [were] auscultated. Code called per full code order. AED (automatic external defibrillator) applied with no shock initiated. CPR (cardiopulmonary resuscitation) immediately initiated and continued until EMTs (Emergency Medical Technicians) arrived. Death [was] pronounced at 0750 (7:50 a.m.). MD (Medical Doctor) and family to be notified. Postmortem care performed.
On 10/7/2021, a Narrative PNs written by the Speech Therapist revealed, Resident #2 had signs and symptoms of a swallowing disorder: Holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications .the Resident is on a mechanically altered therapeutic diet to facilitate oral intake .Liquid Consistency/Solids Texture: Nectar Thick/Mildly Thick Puree .Dysphagia Diagnosis . Resident had cognitive impairment with a history of dementia. Patient (Resident) placed on ST (Speech Therapy) program for dysphagia.
A review of Resident #2's Speech Therapy SLP (Speech Language Pathologist) Discharge summary dated [DATE], under Discharge Recommendations (DR), revealed under Strategies: sit upright during and 30 minutes after oral (by mouth) intake, small single bites/sips, alternate bites/sips .Continue puree/nectar thick liquid diet .
A review of the facility's [NAME] Report (the CNA's plan of care for a resident) as of 10/24/2022 for Resident #2 revealed under the Category of Eating/Nutrition and under Interventions included Provide regular diet and puree nectar/mildly thick liquids consistency per MD (Medical Doctor) order .
A review of a Therapy: Swallow, Cognition and Co-morbidities Communication form dated 4/21/2022 for Resident #2 completed by the Speech Therapist under Speech Therapy Summary Sheet revealed the Resident had 1. Signs and symptoms of a swallowing disorder c. Coughing or choking during meals . and 2. Mechanically altered therapeutic Diet to facilitate oral intake a. Yes, 2-1. Liquid consistency: Nectar Thick/Mildly Thick, 2.2 Solid Texture g. Puree .5. Supported SLP (Speech Language Pathologist) Comorbidities and Diagnosis: .8. Dysphagia Diagnosis .12. Based on Assessment, does the Resident present with evidence of cognitive impairment (Cognitive assessment/orientation) a. Yes, 12-1. Evidence of Cognitive Impairment: history of dementia. 13. Narrative: Completed ST (Speech Therapy) admission screening, Patient (Resident #2) AA&Ox1 (awake, alert & oriented to self). Puree/nectar thick liquid diet (prior level of function). Patient (Resident) not placed on ST program.
A review of the facility's Assignment Sheet for 10/24/2022, on the 11:00 p.m. - 7:00 a.m. shift, revealed that LPN #1 and CNA #1 were on the schedule for Resident #2.
A review of the Time Cards dated 10/16/2022 to 10/29/2022 and 10/30/2022 to 11/12/2022 for CNA #1 revealed she worked on the following dates: 10/24/2022, 10/28/2022, 10/29/2022, 10/31/2022 and 11/2/2022 on the 11:00 p.m. to 7:00 a.m. shifts.
A review of a Teachable Moments (TM) form for LPN #1 revealed, Issue/Reeducation Needed: In-serviced on importance of checking resident diets prior to giving approval for resident meal or snack and where to check. At the bottom of the form, showed Employee signature: printed name of LPN #1 with the Date: 10/25/2022 and Instructor Name/Title: ADON's printed name with the Date: 10/25/2022 and under ADON name was the DON's printed name and date 10/25/2022.
A review of a TM form for CNA #1 revealed Issue/Reeducation Needed: In-serviced on importance of checking resident diets prior to giving approval for resident meal or snack and where to check. At the bottom of the form, indicated Employee signature: printed name of CNA #1 with the Date: 10/25/2022 and Instructor Name/Title: ADON's printed name with the Date: 10/25/2022 and under ADON name was the DON's printed name and date 10/25/2022.
At the time of the survey, the facility could not provide documentation of Resident #2's meal ticket to include his/her meals and snacks for 10/24/2022.
During an interview on 11/3/2022 at 9:36 a.m., the Food Service Director (FSD) stated, each resident's diet is in the meal tracker system, the labeled snacks are individualized to each resident, and sandwiches are made daily. When the surveyor asked him to explain a pureed diet, he replied, a pureed diet is a mousse-like texture of food for people with swallowing problems. He uses a blender to prepare the food. When the surveyor asked him if a sandwich is part of a pureed diet, he replied, No, type of sandwich is considered a puree. Sandwiches are a regular diet. In a second interview at 2:16 p.m., the FSD stated, a peanut butter sandwich is not pureed. It's too hard on the throat and cannot be put into a blender. A peanut butter sandwich is a mechanical Diet.
During an interview on 11/3/2022 at 10:30 a.m. with the Speech Therapist in the presence of the Rehabilitation Director (RD), when the surveyor asked her about the pureed Diet, she replied a pureed diet is soft and smooth, and no, sandwiches are not part of a pureed diet. When the surveyor asked about a tuna fish sandwich, she replied, No, on a pureed [diet], cannot be given a tuna fish sandwich with bread.
During a telephone interview on 11/3/2022 at 10:21 a.m., LPN #1 stated he worked the night shift, but he knew nothing of Resident #2 or of a resident being unresponsive, and he left by 7:00 a.m. 10/25/2022. At 10:44 a.m., LPN #1 stated he does rounds every 2 hours this did not happen on my shift. However, he could not recall the unit's nurse or aides' [CNAs] names.
During an interview on 11/3/2022 at 12:25 p.m., CNA #2 stated she checks on Resident #2 every morning. On 10/25/2022 at approximately 7:15 a.m., the bed was completely flat when she entered his/her room. She thought the Resident was awake, she talked to the Resident, but when there was no response, she touched him/her. Resident #2 was ice cold, so she immediately ran out of the room and told her Charge Nurse/LPN (LPN #2). A Code Blue was called. According to CNA #2, staff came to assist; CPR was started by LPN #2 and LPN #3, and when the paramedics arrived and flipped the sheet, a big, hard cookie flew off the blanket when they pulled the sheets off of the Resident. She continued to say Resident #2 does not usually lay flat, he/she usually sits upright in bed, and he/she is a pureed [diet]. There was no aide to get a report from when she came on the shift. When the surveyor asked if a cookie was allowed on a pureed diet, CNA #2 replied, No, absolutely not. The Resident should not have a cookie; we would give Resident #2 pudding [for a snack]. CNA #2 stated she was with him/her the night before, and the Resident was perfectly fine. CNA #1 admitted to giving Resident #2 cookies and a sandwich. Resident #2 did not die of natural causes. CNA #2 also stated, I was there during CPR; the DON said to me in the room, what happens in this room stays in this room. She showed the cookie to the DON before she left the floor.
At the time of the survey, Resident #2's roommate was not available for an interview.
During an interview on 11/3/2022 at 1:09 p.m., LPN #2 stated, I clocked in at 6:30 a.m., and a code blue was called by (CNA #2). When she entered Resident #2's room to start CPR, the Resident was lying flat with his/her mouth open, and I saw food. She further stated when we turned to put the board [CPR board] under [the Resident], she saw food in the bed. [Resident #2's] mouth was open; I could smell peanut butter, and there was a half-eaten peanut butter sandwich and cookies in bed with [him/her]. When the surveyor asked her if she knew Resident #2's Diet, LPN #2 replied he/she is pureed and wouldn't get a sandwich. A pudding would be the Resident's snack. She continued to say nurses would know the Diet because it is charted on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) and if the aide [CNA] doesn't know the Diet to ask us, the nurses.
During an interview on 11/3/2022 at 1:30 p.m., when the surveyor asked her about a pureed diet and snacks, the Dietician replied, a pureed Diet is [the] consistency of mashed potatoes, food is made in a blender without lumps. She continued, Pureed snacks are pudding, applesauce, ice cream, and pureed fruit.
In the same interview, when the surveyor asked her about a tuna fish sandwich and a peanut butter sandwich, the Dietician replied, tuna fish sandwich is mechanical soft Diet with bread, cut into four pieces, but it is not [a] pureed [Diet]. Puree bread and puree the tuna fish. [A] peanut butter sandwich is a regular texture, and the peanut butter can not be pureed. The Resident could not have a cookie unless pureed and could not have a tuna fish sandwich or a peanut butter sandwich on a pureed diet. We use a company diet manual for diet textures.
During a second interview on 11/3/2022 at 1:42 p.m., when the surveyor asked her if a resident on a pureed diet could eat certain foods, the Speech Therapist (ST), in the presence of the RD, stated, No, a resident on a pureed diet cannot eat a peanut butter sandwich or a hard cookie. The DR said, during and after eating, [Resident #2] should be positioned upright for 30 minutes. She explained sitting up after eating, GI (gastrointestinal), and esophageal issues direct food down into the stomach better, a recommendation for dysphasia like him/her. In the same interview, the RD stated Resident #2 was screened [by Speech] and on [the] most appropriate Diet. On 11/7/2022 at 9:39 a.m., the ST in the presence of the RD, stated a pureed diet cannot have sandwiches.
During an interview on 11/3/2022 at 2:21 p.m., the DON stated CNA #1 said Resident #2 asked for a snack at 4:00 a.m. she went to the snack cart and allegedly asked LPN #1 if it was OK to give Resident #2 a sandwich. CNA #1 went back into Resident #2's room at 5:00 a.m. and gave Resident #2 a tuna fish sandwich, that's it. Resident #2 was next seen by CNA #2, who found him/her unresponsive. I don't know if anyone [was] in there [room] in between. I didn't see any food in [the Resident's] mouth. When the surveyor asked about the food found with Resident #2, the DON replied, I didn't see a cookie, smell peanut butter or find any food in his/her bed. He/she was on a pureed diet, and I would not give someone [Resident] a sandwich on a pureed diet. When the surveyor asked her the outcome of giving a sandwich on a pureed diet, the DON replied, [resident] could choke.
During a telephone interview on 11/3/2022 at 4:43 p.m. with CNA #1, she stated the following happened on 10/25/2022: I was going to rooms, Resident #2 asked for a snack, there was a sandwich out. Resident #2 wanted a tuna fish sandwich. I went to the nurse, and he checked the diet slip. The nurse said, yes, Resident #2 can have a sandwich. Resident #2 was sitting up at 90 degrees. I gave Resident #2 the sandwich at about 4:30 a.m. The CNA stated she saw Resident #2 again between 5:30- 6:00 a.m. when she did her rounds; the Resident was sitting in bed watching television.
During the same telephone interview, the surveyor asked CNA #1 if she knew Resident #2's Diet. She replied, No, I didn't know his/her Diet .so I asked the nurse about the food. That was the only snack I gave him/her; that was it. When the surveyor asked CNA #1 if she was educated on diets, she replied only during her school skills last month; the facility did not provide education. When asked if she was educated or signed any in-services, CNA #1 stated she did not sign anything [paperwork on diet education] and was only suspended for three days after this incident. She returned to work on 10/28/2022.
During an interview on 11/7/2022 at 10:20 a.m., CNA #3 stated CNA #1 said she gave Resident #2 and his/her roommate both snacks that morning. She gave Resident #2 a cookie and a sandwich but did not say what kind of sandwich.
During a telephone interview on 11/7/2022 at 2:22 p.m., the Nurse Practitioner (NP) stated she was just told; Resident #2 had passed away. At the time, the staff did not say anything about the incident surrounding the call. I found out a few days after what happened from the nurses. She continued, Nurses think that (Resident #2) got the wrong Diet and may have choked.
A review of the facility policy titled Therapeutic Diet Policy with a last date revised 09/2022 revealed the following: Under Policy: included therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Under Procedure: .4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner, or Dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the Diet, or to alter the texture of a diet, for example, a. Consistent Carbohydrate; LCS .9. Snacks will be compatible with the therapeutic Diet .
A review of the facility policy titled Care Plans-Comprehensive with a last date revised 10/2019 revealed the following: Under Policy: included A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Procedure: .4. Each resident's care plan will be consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to: .g. Receive the services and/or items included in the plan of care; .13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change .
A review of a facility policy titled Physician Orders with a creation date 2/2022 revealed the following: Under Policy: included It is the policy of this facility to secure physician orders for care and services for residents as required by state and federal law. Physician orders will be dated and signed according to state and federal guidelines.
A review of a facility Diet Manual dated 2021 revealed the following: Under Pureed Diet included Description and Indication The Pureed Diet is designed using the Regular Diet and the mechanically altering the texture of the food items into a pureed consistency. This Diet is indicated for residents with difficulty swallowing and/or residents who are unable to tolerate Ground Soft Diet/Minced and Moist. The goal is to improve or maintain the Resident's nutritional status and provide foods that are safe to swallow, minimizing the chance for aspiration problems. Under Nutritional Adequacy included The Pureed Diet is nutritionally equivalent to the Regular Diet unless any other therapeutic restrictions are specified . Under Preparation of Foods in a Pureed Diet Menu included Food items must be prepared by using a food processor or blender unless food item is already in a pureed form like: mashed potatoes, custard and strained cream soups. Foods are thickened if necessary to achieve a custard or mashed potato consistency using commercial food thickeners or food items like mashed potato flakes. At times it may be necessary to add liquid instead of thickening the food. Liquids used include: gravies, broth, juices or milk. Water is not used since it caused flavor loss then, resulting in poor intake. Product should NOT have any pieces in it and should not thin puree.
A review of the International Dysphagia Diet Standardization Initiative (IDDSI) titled IDDSI Special Feature dated Sept (September) 2020 Focus on Puree revealed the following: Under Why are pureed foods recommended? included .A puree should have a smooth consistency with very fine particles so that chewing is not required. The pureed food is held together with just enough structure and is slippery enough so that it can be moved from the front of the mouth to the back and swallowed with minimal effort. These factors promote a safe way to consume food when oral coordination or strength is impaired .
N.J.A.C.: 8.39-17.4 (a)(2)
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Comprehensive Care Plan
(Tag F0656)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ159249
Based on interviews, medical records review, and review of other pertinent facility documentation on 11/3/2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ159249
Based on interviews, medical records review, and review of other pertinent facility documentation on 11/3/2022 and 11/7/2022, it was determined that the facility failed to implement a comprehensive care plan (CP) for a resident on a regular diet pureed texture, Nectar Thick, Mildly Thick Consistency for 1 of 3 residents (Resident #2). The facility also failed to follow its policy titled Comprehensive Care Plan .This deficient practice was evident in 1 of 3 care plans, as evidenced by the following:
According to the admission Record (AR), Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Oropharyngeal Phase Dysphagia, Unspecified Cerebral Infarction, and Hemiplegia and Hemiparesis following Cerebral Infarction.
According to the Minimum Data Set (MDS), an assessment tool dated 10/01/2022, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 3/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #2 needed extensive assistance with most Activities of Daily Living (ADLs) and was totally dependent on staff for eating.
A review of the Resident's Care Plan (CP) initiated on 06/24/2021 revealed under Focus: Nutrition problem: r/t (related/to) moderate malnutrition, mech (mechanical) altered diet, dysphagia, significant weight loss x 1 mos (month), decreased PO (by mouth) intake. The CP also included under Goal: Resident will be adequately nourished and hydrated via intake from meals and fluids through the review date. Also, under Interventions: included, .Provide regular diet and puree nectar/mildly thick liquids consistency per MD (Physician) order .
During an interview on 11/7/2022 at 11:00 a.m., the Assistant Director of Nursing (ADON) stated, the purpose of the CP is to know how to care for residents, meet their needs, set goals and interventions. When the surveyor asked him if the CP was followed for the Resident, he replied, Resident #2's care plan was not followed according to his/her diet since he/she received a sandwich and his/her family and the doctor (Physician) should have been notified of the wrong diet given.
During an interview on 11/7/2022 at 1:04 p.m., the DON stated, the purpose of the CP is to know what to do with the Resident and to keep them safe. The CP for Resident #2 was not followed because they gave him/her a sandwich
A review of the facility policy titled Care Plans-Comprehensive with a last date revised 10/2019 revealed the following: Under Policy: included A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under Procedure: .4. Each resident's care plan will be consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to: .g. Receive the services and/or items included in the plan of care; .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .
N.J.A.C.: 8.39-27.1 (a)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REF: F808
Complaint#: NJ159249
Based on interviews, medical records review, and review of other pertinent facility documentation...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REF: F808
Complaint#: NJ159249
Based on interviews, medical records review, and review of other pertinent facility documentation on 11/3/2022 and 11/7/2022, it was determined that the facility failed to notify the responsible party and Physician of the incorrect therapeutic diet served to a resident (Resident #2). The facility also failed to follow its policies titled Notifications and Charting and Documentation.This deficient practice was identified for 1 of 3 residents (Resident #2) and was evidenced by the following:
According to the admission Record (AR), Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Oropharyngeal Phase Dysphagia, Unspecified Cerebral Infarction, and Hemiplegia and Hemiparesis following Cerebral Infarction.
According to the Minimum Data Set (MDS), an assessment tool dated 10/01/2022, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 3/15, which indicated the Resident was severely cognitively impaired. The MDS also showed Resident #2 needed extensive assistance with most Activities of Daily Living (ADLs) and was dependent on staff for eating.
A review of Resident #2's Order Summary Report (OSR) dated Active Orders as of 10/25/2022 under Dietary-Diet revealed under Order Summary Regular diet Puree texture, Nectar Thick/Mildly Thick consistency for diet dated 4/21/2022.
A review of Resident #2's Progress Notes (PNs) dated 10/25/2022 at 8:26 a.m., written by the Director of Nursing (DON), revealed Registered Nurse (RN) Assessment called to (the) Resident room. Resident (Resident #2) (was) not breathing and was unresponsive at approximately 0720 (7:20 a.m.). No respirations, apical pulse, or heart/breath sounds auscultated. Code called per full code order. AED (automatic external defibrillator) applied with no shock initiated. CPR (cardiopulmonary resuscitation) immediately initiated and continued until EMTs (Emergency Medical Technicians) arrived. Death (was) pronounced at 0750 (7:50 a.m.). MD (Medical Doctor) and family to be notified.
During an interview on 11/7/2022 at 11:00 a.m., the Assistant Director of Nursing (ADON) stated, I don't know if the family and Physician were notified of [the] wrong diet. I came after the fact. Yes, the family and Physician should have been notified either by the Unit Manager (UM) or [the] nurse that Resident #2 got the wrong diet. I don't know if they were notified.
During an interview on 11/7/2022 at 1:04 p.m., the surveyor asked if the family and the Physician were notified of the wrong diet being served. The DON stated, I don't know if the family and Physician were notified about [the] wrong diet. They were notified of the [Resident] passing. The DON continued to say yes, the family should have been notified too about the wrong diet.
During an interview on 11/7/2022 at 1:25 p.m., the surveyor asked about notifying the family and the Physician about Resident #2's receiving the wrong diet. The UM/Registered Nurse (UM/RN) stated, No, at that time, I didn't know anything about the diet. I just said he/she passed away. I would assume so to notify the family of the wrong diet. It could be anyone to notify the family, nurse, ADON, Dietician, or DON, not solely the UM. Honestly I don't know if the PCP (Primary Care Physician) was notified.
During a telephone interview on 11/7/2022 at 2:17 p.m., the Physician stated he was familiar with Resident #2, but he was not personally notified of his/her death. He continued to say the Nurse Practitioner (NP) would have been notified of the death; the NP takes [phone] calls during the day for the facility.
During a telephone interview on 11/7/2022 at 2:17 p.m., the Physician stated he was familiar with Resident #2, but he was not personnally notified of his/her death. He continued to say the NP would have been notified of the death; the NP takes [phone] calls during the day for the facility.
During a telephone interview on 11/7/2022 at 2:22 p.m., the NP stated she was just told; Resident #2 had passed away. I'm not sure if they called on-call [service], and I was told. At the time, the staff did not say anything about the incident surrounding the call. I found out a few days after what happened from the nurses. She continued to say Nurses think that Resident #2 got the wrong Diet and may have choked. I didn't get the whole story about the food until after.
A review of the facility policy titled Notifications, creation date 4/2022 revealed the following: Under Policy: included Except in a medical emergency, the facility must consult with the resident immediately if the resident is competent, and notify the resident's Physician an designated representative when there is: .a significant improvement or decline in the resident's physical, mental, or psychosocial status (i.e. a deterioration in health, .) .Immediately shall mean as soon as possible . Under Procedure: Significant Change in Condition indicated .b) Nurse immediately notifies resident and designated representative of any significant alteration in treatment .d) Notification is documented in nurses notes and reflects name of person notified and the change in condition/treatment .
A review of the facility policy titled Charting and Documentation last date revised 1/2022 revealed the following: Under Policy included All services provided to the resident, or any changes in the resident's medical condition, shall be documented in the resident's medical record. Under Procedure: .2. Entries may only be recorded in the Resident's clinical record by licensed personnel (e.g. (for example) RN, LPN/LVN, Physicians, therapists, etc.) in accordance with state law and facility policy .6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum .f. Notification of family, Physician and other staff, if indicated; g. The signature and title of the individual documenting.
N.J.A.C. 8.39-13.1 (c), (d)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REF: F808
Complaint#: NJ159249
Based on observations, interviews, medical record reviews, and review of other pertinent facilit...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** REF: F808
Complaint#: NJ159249
Based on observations, interviews, medical record reviews, and review of other pertinent facility documentation on 11/3/2022 and 11/7/2022, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH), the investigation of a resident (Resident #2) who was on a puree diet, served a sandwich and later died. The facility also failed to follow its policy titled Incidents and Accidents. This deficient practice was identified for 1 of 3 residents (Resident #2) and was evidenced by the following:
Review of the electronic Medical Record was as follows:
According to the admission Record (AR), Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included but were not limited to Oropharyngeal Phase Dysphagia, Unspecified Cerebral Infarction, and Hemiplegia and Hemiparesis following Cerebral Infarction.
According to the Minimum Data Set (MDS), an assessment tool dated 10/01/2022, Resident # 2 had a Brief Interview of Mental Status (BIMS) score of 3/15, which indicated the ResidentResident was severely cognitively impaired. The MDS also showed Resident #2 needed extensive assistance with most Activities of Daily Living (ADLs) and was totally dependent on staff for eating.
A review of the Resident's Care Plan (CP) initiated on 06/24/2021 revealed under Focus: Nutrition problem: r/t (related/to) moderate malnutrition, mech (mechanical) altered diet, dysphagia, significant weight loss x 1 mos (month), decreased PO (by mouth) intake. The CP also included under Goal: Resident will be adequately nourished and hydrated via intake from meals and fluids through the review date. Also, under Interventions: included, .Provide regular Diet and puree nectar/mildly thick liquids consistency per MD (Physician) order .
A review of Resident #2's Order Summary Report (OSR) dated Active Orders as of 10/25/2022 under Dietary-Diet revealed under Order Summary Regular diet Puree texture, Nectar Thick/Mildly Thick consistency for diet dated 4/21/2022.
A review of Resident #2's Progress Notes (PNs) dated 10/25/2022 at 8:26 a.m., written by the Director of Nursing (DON), revealed Registered Nurse (RN) Assessment called to [the] Resident room. Resident (Resident #2) [was] not breathing and was unresponsive at approximately 0720 (7:20 a.m.). No respirations, apical pulse, or heart/breath sounds [were] auscultated. Code called per full code order. AED (automatic external defibrillator) applied with no shock initiated. CPR (cardiopulmonary resuscitation) immediately initiated and continued until EMTs (Emergency Medical Technicians) arrived. Death [was] pronounced at 0750 (7:50 a.m.). MD (Physician) and family are to be notified.
During an interview on 11/3/2022 at 12:25 p.m., CNA #2 stated she checks on Resident #2 every morning. On 10/25/2022 at approximately 7:15 a.m., the bed was completely flat when she entered his/her room. She thought the Resident was awake, she talked to the Resident, but when there was no response, she touched him/her. Resident #2 was ice cold, so she immediately ran out of the room and told her Charge Nurse/LPN (LPN #2). A Code Blue was called. According to CNA #2, staff came to assist; CPR was started by LPN #2 and LPN #3, and when the paramedics arrived and flipped the sheet, a big, hard cookie flew off the blanket when they pulled the sheets off of the Resident. She continued to say Resident #2 does not usually lay flat, he/she usually sits upright in bed, and he/she is a pureed [diet]. There was no aide to get a report from when she came on the shift. When the surveyor asked if a cookie was allowed on a pureed diet, CNA #2 replied, No, absolutely not. The Resident should not have a cookie; we would give Resident #2 pudding [for a snack]. CNA #2 stated she was with him/her the night before, and the Resident was perfectly fine and CNA #1 admitted to giving Resident #2 cookies and a sandwich. Resident #2 did not die of natural causes. CNA #2 also stated, I was there during CPR, the DON said to me in the room, what happens in this room stays in this room. She continued to say she showed the cookie to the DON before she left the floor.
During an interview on 11/3/2022 at 1:09 p.m., LPN #2 stated, I clocked in at 6:30 a.m., and a code blue was called by CNA #2. Another nurse (LPN #3) and I entered Resident #2's room and started CPR. Resident #2 was lying flat with his/her mouth open, and I saw food. She further stated when we turned to put the board [CPR board] under [the Resident], she saw food in the bed. Resident #2's mouth was open; I could smell peanut butter, and there was a half-eaten peanut butter sandwich and cookies in bed with [him/her].
In the same interview, when the surveyor asked her if she knew Resident #2's Diet, LPN #2 replied he/she is pureed and wouldn't get a sandwich. A pudding would be the Resident's snack. She continued to say nurses would know the Diet because it is charted on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) and if the aide [CNA] doesn't know the Diet to ask us, the nurses.
During an interview on 11/3/2022 at 2:21 p.m., When the surveyor asked the DON if she did an investigation, she replied, I did a risk report, and I have statements from LPN #1 and CNA #1, but there are no other statements from 7:00 a.m.-3:00 p.m. shift staff.
During a telephone interview on 11/3/2022 at 4:43 p.m. with CNA #1, she stated the following happened on 10/25/2022: I was going to rooms, Resident #2 asked for a snack, there was a sandwich out. Resident #2 wanted a tuna fish sandwich. I went to the nurse, and he checked the diet slip. The nurse said, yes, Resident #2 can have a sandwich. Resident #2 was sitting up at 90 degrees. I gave Resident #2 the sandwich at about 4:30 a.m. I unwrapped the sandwich, and he/she ate a couple of bites, then I disposed of the rest. Resident #2 said to me he/she was good. The Resident enjoyed it [sandwich]. Resident #2 was fine at 5:30- 6:00 a.m., when she did her rounds, changed, and the Resident watched TV [television] sitting up in bed. During a telephone interview on 11/3/2022 at 4:43 p.m. with CNA #1, she stated the following happened on 10/25/2022: I was going to rooms, Resident #2 asked for a snack, there was a sandwich out. Resident #2 wanted a tuna fish sandwich. I went to the nurse, and he checked the diet slip. The nurse said, yes, Resident #2 can have a sandwich. Resident #2 was sitting up at 90 degrees. I gave Resident #2 the sandwich at about 4:30 a.m. The CNA stated she saw Resident #2 again between 5:30- 6:00 a.m. when she did her rounds; the Resident was sitting in bed watching television.
During the same telephone interview, the surveyor asked CNA #1 if she knew Resident #2's Diet. She replied, No, I didn't know his/her Diet .so I asked the nurse about the food. That was the only snack I gave him/her; that was it. When the surveyor asked CNA #1 if she was educated on diets, she replied only during her school skills last month; the facility did not provide education. When asked if she was educated or signed any in-services, CNA #1 stated she did not sign anything [paperwork on diet education] and was only suspended for three days after this incident. She returned to work on 10/28/2022.
A review of the facility policy Incidents and Accidents, date revised 7/2020 revealed the following: Under POLICY: It is the policy of the facility to monitor and evaluate all occurrences of accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine operation of the facility or care of a particular resident. These occurrences must be evaluated an investigated. Under Reporting indicated .7. It [If] the ResidentResident has sustained any suspected or actual significant injury, is sent to the hospital or abuse is suspected, the supervisor/manager must notify immediately the Administrator/Director of Nurses. 8. The Supervisor/Manager will begin the investigation for root causes of the occurrence .12. DON and Admin [Administrator] responsible to review incident/investigation and conclusion to determine if incident requires reporting to outside agencies such as; DOH (Department of Health), OIG (Office of Inspector General), CMS (Centers for Medicare & Medicaid), etc . Under Evaluation 13. All incidents and Accidents will be evaluated when applicable by the interdisciplinary team. 14. The team will review the investigation and continue if necessary, discuss and determine from the investigation the root causes, make recommendations for additional intervention, education, and conclude the investigation .
N.J.A.C.: 8:39-13.4 (c) 2 (iv) (v)
Sept 2022
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and review of other pertinent facility documentation, it was determined the facility failed to maintain an orderly and sanitary environment by leaving garbage bags, a ...
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Based on observation, interview, and review of other pertinent facility documentation, it was determined the facility failed to maintain an orderly and sanitary environment by leaving garbage bags, a spill, gowns, linens, and unpackaged incontinence briefs in the hallway of B unit. The deficient practice was identified for 1 of 4 wings (B Wing) on the first floor and was evidenced by the following:
On 8/31/22 at 10:26 AM, in the B Wing, the surveyor observed two trash bags filled with garbage unattended on the floor. The surveyor also observed linen with unpackaged incontinence briefs left on top of a plastic supply bin in the hallway. Further, the surveyor observed another opened bag of incontinence briefs on a chair in the hallway.
On 09/01/22 at 9:54 AM, the surveyor observed a red trash bin used for personal protective equipment (PPE) (equipment such as, but not limited to gowns, gloves, and eye protection worn to create a barrier from pathogens) overflowing with pieces of used gowns. The surveyor also observed an opened package of incontinence briefs on a chair and towels left on a wheelchair in the hallway.
On 09/02/22 at 12:10 PM, the surveyor observed two trash bags filled with used gowns unattended on the floor in the hallway.
On 09/06/22 at 11:46 AM, the surveyor observed unpackaged incontinence briefs and linen left on top of a bedside table located in the hallway.
On 09/07/22 at 10:10 AM, the surveyor observed spilled liquid on the floor of the hallway.
On 09/12/22 at 9:11 AM, during an interview with the surveyor, the Director of Housekeeping confirmed after reviewing the surveyor's evidence that garbage bags should not be left in the hallway on the floor or tied to the railing by stating, That's not good. He further confirmed that the spill should have been attended to with a wet floor sign and a notification to housekeeping.
On 09/12/22 at 1:27 PM, during an interview with the surveyor, the Director of Nursing confirmed linen and unpackaged incontinence briefs should not be left in the hallway.
On 09/13/22 at 10:53 AM, during an interview with the surveyor, the Regional Director of Clinical Services stated that linen and unpackaged incontinent briefs should be stored appropriately due to contamination.
A review of the facility policy titled Disinfecting/Cleaning Environmental Surfaces with a revised date of 3/2022 revealed under Procedure number 9; Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled.
A review of the facility policy titled, Linen Storage revealed under Procedure number 2; Facility will supply units with a par amount of laundry that is stored in a designated closet on each unit.
The facility was unable to provide a policy for the storage of full trash bags.
N.J.A.C. 8:39-31.4(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to rep...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) a.) an allegation of physical and verbal abuse for 1 of 1 resident (Resident #134) reviewed for abuse and b.) an unwitnessed event resulting in major injury for 1 of 3 residents (Resident #41) reviewed for falls.
This deficient practice was evidenced by the following:
1. On 09/01/22, the surveyor requested the personnel files for five employees hired within the last four months.
Review of Certified Nursing Assistant (CNA) #8's personnel file revealed an Employee Warning Record (EWR), dated 08/02/22, that included a conduct violation with a violation date of 07/31/22 at 11:00 AM in Resident #134's room. Further review of the EWR revealed [Resident #134] stated that [CNA #8] was mean and degrading. CNA called resident nasty and refused to place resident on toilet, and pulled resident's arm and [Resident #134] was scared that CNA was going to break [his/her] arm. Resident was in tears and had to be calmed down by staff. The EWR was signed by the Director of Nursing (DON).
The surveyor requested the Facility Reported Incidents (FRI) for July and August of 2022. The facility was unable to provide the FRI for Resident #134's allegation of physical and verbal abuse.
On 09/06/22 at 10:03 AM, the surveyor observed Resident #134 lying in bed. When asked about the allegation against CNA #8, the resident was unable to recall any specific details.
According to the admission Record, Resident #134 was admitted with diagnoses which included, but were not limited to, encephalopathy (brain disease that alters brain function) and dementia.
Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 05/31/22, revealed the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident's cognition was intact. Further review of the MDS revealed the resident did not exhibit any behaviors and required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene.
Review of the Care Plan included a focus of Resident is at risk for misappropriation, neglect, abuse and/or exploitation r/t [related to] ltc [Long-Term Care], dated 01/21/22, with interventions to investigate all allegations of abuse and neglect promptly, and, Report to MD and initiate assessment. Further review of the Care Plan included a focus of Resident exhibits behavior symptoms . 7/31 made allegation against C.N.A.; follow up the following day revealed the resident had no recollection of the allegation, created on 09/06/22 by the Regional Director of Clinical Services.
Review of the Progress Notes, dated 07/31/22 through 08/06/22, did not include any mention of the resident's allegation, assessment of the resident, or notification of the allegation to the NJDOH.
Review of the Assessments section in the Electronic Medical Record (EMR) revealed an Initial Event Documentation, dated 08/03/22, which included, Date/Time of Event OR When Nursing Became Aware Of Event: 07/31/22 11:00 and, UM [Unit Manager] was made aware by resident's nurse that resident wanted to complain about [his/her] aid. UM asked nurse what happened and the nurse stated that the resident felt disrespected and embarrassed by [his/her] care. When UM went in to talk to resident, resident stated that nothing happened and didn't appear to be upset about anything.
Further review of the Assessments section of the EMR included a skin assessment, dated 08/02/22, which revealed there were no new skin issues. There were no assessments that included a physical assessment of the resident for 07/31/22.
During an interview with the surveyor on 09/06/22 at 11:00 AM, the DON verified there were no additional FRIs for July and August 2022 other than the ones previously provided to the surveyor. When asked about the abuse allegation made against CNA #8 in the EWR, the DON stated she was unfamiliar with the allegation and would have to speak to the supervisor who completed the EWR. The DON further stated that she was unsure if the allegation was reported to the NJDOH.
At 12:45 PM, the DON provided the surveyor with a soft file for Resident #134's allegation that was stored in Licensed Practical Nurse/Unit Manager (LPN/UM) #3's office.
Review of the soft file included a Full QA Report, with an incident date/time of Sunday, July 31, 2022 11:00 AM. Further review of the report revealed it included the same statement made by LPN/UM #3 in the Initial Event Documentation. The report also included a witness statement from the Infection Control Preventionist (ICP) of I was making I.C. [Infection Control] rounds when I overheard [CNA #8] from resident's room in an unprofessional tone. I removed CNA from resident's room and spoke to her regarding her tone. According to the report, the DON and the Licensed Nursing Home Administrator (LNHA) were made aware of the allegation on 07/31/22 at 11:15 AM. The report did not include a statement from Resident #134's assigned nurse or any mention of notifying the NJDOH.
During an interview with the surveyor on 09/06/22 at 1:12 PM, the Registered Nurse/Unit Manager (RN/UM) explained the process for an allegation of abuse included assessing the resident for changes in skin condition and pain, collecting statements from staff and residents, notifying the supervisor, physician, and resident's representative, and filling out an incident report. The RN/UM further stated she was the current UM for Resident #134, and that the resident knows his/her name, but is confused.
During an interview with the surveyor on 09/06/22 at 1:21 PM, LPN/UM #1 explained the process for an allegation of abuse included starting the investigation, gathering statements, notifying the DON, and reporting the allegation to the NJDOH. LPN/UM #1 further stated that she was the UM for Resident #134 at the end of July 2022, and that it was hard to tell if [he/she] was alert and oriented.
During an interview with the surveyor on 09/06/22 at 1:39 PM, LPN/UM #3 explained the process for an allegation of abuse included interviewing the resident, assessing the resident for injury, ensuring the resident is safe, interviewing staff, documenting in the Initial Event Documentation or the progress notes, and notifying the DON to determine if it was a FRI. When asked about the EWR completed by LPN/UM #3 for CNA #8, LPN/UM #3 stated she was the supervisor on 07/31/22 when Resident #134 stated CNA #8 was rough with [him/her]. LPN/UM #3 further stated that she assessed the resident's body due to a complaint that CNA #8 rubbed [him/her] too hard with care, but that there were no skin issues, complaints of pain, or change in range of motion. LPN/UM #3 then stated she notified the DON that same day and completed the EWR for CNA #8. She also stated that when she interviewed Resident #134 the following day, the resident was unable to recall the allegation.
During an interview with the surveyor on 09/06/22 at 1:56 PM, the ICP explained the process for an allegation of abuse included completing an investigation, collecting statements, and notifying the NJDOH within two hours. When asked about the abuse allegation made by Resident #134, the ICP stated that she was performing rounds when she happened to walk up on the conversation between Resident #134 and CNA #8. The ICP stated that the CNA was speaking unprofessionally to the resident and that the ICP spoke to CNA #8 about professionalism. When asked if the ICP was present in the Resident #134's room the entire time CNA #8 was performing care, the ICP stated CNA #8 was already in the room when she entered and that she did not witness the care performed by the CNA in its entirety.
During a telephone interview with the surveyor on 09/08/22 at 10:35 AM, CNA #8 stated that on the day of Resident #134's allegation, she was sent home and allowed to return to work two days later. The CNA stated the alleged incident did not occur and was unaware of the results of the investigation.
During a telephone interview with the surveyor on 09/08/22 at 11:22 AM, the Agency Nurse assigned to Resident #134 on 07/31/22 stated that she entered Resident #134's room and the resident was crying. When the Agency Nurse asked if the resident was going to eat [his/her] meal, the resident stated [he/she] wanted to speak to a supervisor. The Agency Nurse further stated that the resident did not go into any details about the complaint, and that she notified LPN/UM #3 who was the supervisor for that shift.
During a follow-up interview with the surveyor on 09/08/22 at 12:18 PM, the ICP stated she could not recall specifically what the CNA said to the resident, but that the CNA's tone was louder than normal, and the resident perceived the CNA's speech as a rough manner.
During a follow-up interview with the surveyor on 09/09/22 at 12:15 PM, the DON explained the process for an allegation of abuse included separating the involved parties, interviewing anyone present including staff and residents, obtaining written statements that are signed, assessing the resident, notifying the resident's family and physician, notifying the NJDOH within two hours, completing an investigation report, and notifying the NJDOH of the conclusion to the investigation. When asked about the abuse allegation made by Resident #134, the DON stated that she was notified of the incident on 07/31/22 and was told that the resident reported that CNA #8 was rude, aggressive, and pulled the resident's arm. The DON further stated that she instructed LPN/UM #3 to obtain statements and send CNA #8 home pending the investigation. The DON then stated that the abuse allegation was not reported to the NJDOH because the ICP witnessed the incident and stated it did not occur. However, the DON stated that if the alleged incident was not witnessed in its entirety, the allegation should have been reported to the NJDOH. When asked about the conclusion to the allegation investigation, the DON stated she typed up a conclusion, emailed it to the NJDOH, and kept a copy in her office.
At that time, the surveyor accompanied the DON to her office to obtain a copy of the conclusion to the allegation investigation. The DON was unable to locate the conclusion in her office and was also unable to locate any email sent to the NJDOH after 07/29/22. The DON stated, If I didn't report it, I wouldn't have emailed the conclusion to the NJDOH.
On 09/13/22, the facility provided a copy of a Grievance Form related to Resident #134's allegation of abuse, dated 08/01/22, which included, Resident had alleged on 07/31/22 that a CNA was rough with [him/her] while getting care. Resident stated that CNA nasty to [him/her] and [he/she] felt degraded, and was signed by LPN/UM #3. Further review of the Grievance Form included, To ensure abuse and neglect are ruled out promptly, does this grievance require further investigation? Yes, and, Was the Department of Health and/or local police notified? No. The Grievance Form was signed by the LNHA on 08/03/22.
During an interview with the surveyor on 09/13/22 at 11:31 AM, the LNHA stated that he was unable to recall when he was notified of the alleged abuse between Resident #134 and CNA #8. The LNHA further stated that the DON was responsible for completing the investigation, but he was unable to recall when the results of the investigation were reported to him. The LNHA also stated that he did not believe the allegation or the conclusion to the investigation were reported to the NJDOH, but that any allegation of abuse should be reported.
Review of the facility's Abuse policy, revised 02/2022, included, Allegations/reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management, and, The Shift Supervisor/Charge Nurse is identified as responsible for immediate initiation of the reporting process upon receipt of the allegation. Further review of the policy revealed, Notify the local law enforcement and appropriate State Agency(s) immediately (no later than 2 hours after allegation/identification of allegation) by Agency's designated process after identification of alleged/suspected incident, and, Report results of investigation to the proper authorities as required by State law.
2. On 08/30/22 at 11:12 AM the surveyor, while on the initial tour of the facility, observed Resident #41 in his/her room. Resident #41 had no socks and was observed to be lying in bed. Resident #41 complained of breaking his/her leg. The surveyor questioned Resident #41 how this event occurred, but he/she was not sure how. Resident #41 stated, I guess I fell.
According to the most recent admission Record, Resident 41 was admitted to the facility with the following, but not limited to, diagnoses: Age-related osteoporosis (micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk), displaced fracture of lateral condyle of left femur, repeated falls, morbid obesity, Alzheimer's disease, and cerebral infarction.
Review of the comprehensive Significant Change MDS dated [DATE], revealed that Resident #41 had a BIMS score of 06 indicating severe cognitive impairment. According to Section G, Resident #41 required extensive assistance of staff with bed mobility and was totally dependant of staff with transfers. Section J revealed that Resident #41 had a fall history; and according to Section P, Resident #41 had no restraints or alarms in place.
Review of the comprehensive interdisciplinary care plan revealed Resident #41 had a Focus of is at risk for falls r/t (related to) Alzheimer's Disease, limited mobility.
On 09/01/22, the surveyor reviewed the Electronic Medical Record. A progress note dated 05/27/22 revealed that Resident #41 at 7:40 PM was found by CNA on floor beside [his/her] bed. Resident was in a semi sitting position with [his/her] back and head against bed and legs turned to the left in front of [him/her]. Resident denies hitting [his/her] head but stated [his/her] leg hurt. The progress notes further revealed that Resident #41 was sent out to the hospital by ambulance to be evaluated, and Resident #41 was admitted to hospital with dx [diagnosis] of left femur displaced fx [fracture].
On 09/07/22 at 10:36 AM, the Corporate Assistant Director of Nursing provided the surveyor with Resident #41's Full QA Report, dated 05/27/22. The nurses' Investigative Statements revealed the following: Resident was found by CNA on floor beside [his/her] bed. Resident was in a semi sitting position with [his/her] back and head against the bed and legs turned to the left in front of [him/her]. Resident denies hitting [his/her] head but stated [his/her] leg hurt. According to the CNA Investigative Statement, While doing rounds resident was observed sitting on floor beside [his/her] bed in room. Notified nurse immediately. The QA Report concluded that Resident displays poor safety awareness. Resident was observed sitting on floor beside bed and c/o [complained of] leg pain. MD ordered for resident to be sent to ED [emergency department] for evaluation and treatment. This investigation revealed that this occurrence was unavoidable due to clinical condition and noncompliance. There is no reason to believe that any alleged abuse, neglect, mistreatment, or misappropriation has occurred.
On 09/07/22 at 11:17 AM, the surveyor conducted an interview with the facility DON. The surveyor questioned the facility DON if she had reported Resident #41's 05/27/22 incident as a reportable to the NJDOH. The DON responded, As far as I know it is not a reportable event. [He/she] fell. The surveyor then explained that the resident had a fall with a major injury that was unwitnessed by facility staff, how did the facility know that the resident fell if it was unwitnessed. The DON replied, Looking at the report, I can see what you mean. The surveyor clarified, and the DON confirmed, that the CNA on duty that found Resident #41 on the floor did not witness Resident #41 fall. The CNA found the resident on the floor. The surveyor asked the DON who was responsible for reporting unwitnessed events that resulted in major injury to the NJDOH. The DON responded, I am the one responsible for reporting a reportable event if one should occur. The surveyor questioned the DON if she was aware of the time frame for reporting a reportable event that occurred in the facility. The DON explained, The time frame is that I should call the state within 1 hour. I also report for weekends and off shifts. It has to be reported within 1 hour. The DON then agreed that she did not report the event because the facility assumed that the resident fell when it was an unwitnessed event.
On 09/12/22 at 01:34 PM, the surveyors conducted an interview with the facility DON, Licensed Nursing Home Administrator (LNHA), and Regional Director of Clinical Services. The surveyor again questioned the DON if the unwitnessed event that occurred with Resident #41 on 05/27/22 at 7:40 PM should be considered a reportable event and should have been reported to the NJDOH. The DON stated, If it was unwitnessed, yes, it's a reportable event. The surveyor questioned why staff did not ask Resident #41 what happened during the nursing assessment. The DON stated, I'm not sure if the resident would be able to tell you what happened.
The surveyor reviewed the facility policy titled Investigation - Injuries of Unknown Etiology, Policy No: CI-3, last date revised: 11/2021. The following was revealed under the heading POLICY: An investigation of all injuries of unknown etiology (including bruises, abrasions, and injuries of unknown source) will be conducted by an individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized, and to investigate any potential abuse or neglect.
According to the PROCEDURE:
3. Injury of Unknown Etiology is defined as an injury that meets both of the following conditions:
a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and
b. The injury is suspicious because of:
the extent of the injury; or
the location of the injury) e.g., the injury is located in an area not generally vulnerable to trauma); or
the number of injuries observed at one particular point in time; or
the incidence of injuries over time.
The surveyor reviewed the facility policy titled Investigations, How to Conduct, POLICY NO: CI-1, last date revised: 11/2021. The policy failed to address that a resident that suffers an unwitnessed event with a major injury is a reportable event.
NJAC 8:39-9.4 (f)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to thoroughly investigate an allegation of physical and verbal abuse for 1 of ...
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Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to thoroughly investigate an allegation of physical and verbal abuse for 1 of 1 resident (Resident #134) reviewed for abuse.
This deficient practice was evidenced by the following:
On 09/01/22, the surveyor requested the personnel files for five employees hired within the last four months.
Review of Certified Nursing Assistant (CNA) #8's personnel file revealed an Employee Warning Record (EWR), dated 08/02/22, that included a conduct violation with a violation date of 07/31/22 at 11:00 AM in Resident #134's room. Further review of the EWR revealed [Resident #134] stated that [CNA #8] was mean and degrading. CNA called resident nasty and refused to place resident on toilet, and pulled resident's arm and [Resident #134] was scared that CNA was going to break [his/her] arm. Resident was in tears and had to be calmed down by staff. The EWR was signed by the Director of Nursing (DON).
On 09/06/22 at 10:03 AM, the surveyor observed Resident #134 lying in bed. When asked about the allegation against CNA #8, the resident was unable to recall any specific details.
According to the admission Record, Resident #134 was admitted with diagnoses which included, but were not limited to, encephalopathy (brain disease that alters brain function) and dementia.
Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 05/31/22, revealed the resident had a Brief Interview for Mental Status of 15 indicating the resident's cognition was intact. Further review of the MDS revealed the resident did not exhibit any behaviors and required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene.
Review of the Care Plan included a focus of Resident is at risk for misappropriation, neglect, abuse and/or exploitation r/t [related to] ltc [Long-Term Care], dated 01/21/22, with interventions to investigate all allegations of abuse and neglect promptly, and, Report to MD and initiate assessment. Further review of the Care Plan included a focus of Resident exhibits behavior symptoms . 7/31 made allegation against C.N.A.; follow up the following day revealed the resident had no recollection of the allegation, created on 09/06/22 by the Regional Director of Clinical Services.
Review of the Progress Notes, dated 07/31/22 through 08/06/2022, did not include any mention of the resident's allegation or physical assessment of the resident.
Review of the Assessments section in the Electronic Medical Record (EMR) revealed an Initial Event Documentation, dated 08/03/22, which included, Date/Time of Event OR When Nursing Became Aware Of Event: 07/31/2022 11:00 and, UM [Unit Manager] was made aware by resident's nurse that resident wanted to complain about [his/her] aid. UM asked nurse what happened and the nurse stated that the resident felt disrespected and embarrassed by [his/her] care. When UM went in to talk to resident, resident stated that nothing happened and didn't appear to be upset about anything.
Further review of the Assessments section of the EMR included a skin assessment, dated 08/02/22, which revealed there were no new skin issues. There were no assessments that included a physical assessment of the resident for 07/31/22.
During an interview with the surveyor on 09/06/22 at 11:00 AM, the DON stated she was unfamiliar with the abuse allegation made by Resident #134 and would have to speak to the supervisor who completed the EWR.
At 12:45 PM, the DON provided the surveyor with a soft file for Resident #134's allegation that was stored in Licensed Practical Nurse/Unit Manager (LPN/UM) #3's office.
Review of the soft file included a Full QA Report (incident report), with an incident date/time of Sunday, July 31, 2022 11:00 AM. Further review of the report revealed it included the same statement made by LPN/UM #3 in the Initial Event Documentation. The report also included a witness statement from the Infection Control Preventionist (ICP) of I was making I.C. [Infection Control] rounds when I overheard [CNA #8] from resident's room in an unprofessional tone. I removed CNA from resident's room and spoke to her regarding her tone. According to the report, the DON and the Licensed Nursing Home Administrator (LNHA) were made aware of the allegation on 07/31/22 at 11:15 AM. The report did not include a statement from Resident #134's assigned nurse or the resident's roommate, and the statements included were not written or signed by the person making the statement.
The surveyor requested the name of the Resident #134's roommate at the time of the alleged incident from the Admissions Office and was provided with Resident #133's information.
Review of Resident #133's Social Service Assessment, dated 07/25/22, revealed [Resident #133] presents AAOX3 [cognitively intact] and is able to make [his/her] needs and wants to be known to the staff.
During an interview with the surveyor on 09/06/22 at 1:12 PM, the Registered Nurse/Unit Manager (RN/UM) explained the process for an allegation of abuse included assessing the resident for changes in skin condition and pain, collecting statements from staff and residents, notifying the supervisor, physician, and resident's representative, and filling out an incident report. The RN/UM further stated she was the current UM for Resident #134, and that the resident knows his/her name, but is confused.
During an interview with the surveyor on 09/06/22 at 1:21 PM, LPN/UM #1 explained the process for an allegation of abuse included starting the investigation, gathering statements, notifying the DON, and reporting the allegation to the NJDOH. LPN/UM #1 further stated that she was the UM for Resident #134 at the end of July 2022, and that it was hard to tell if [he/she] was alert and oriented.
During an interview with the surveyor on 09/06/22 at 1:39 PM, LPN/UM #3 explained the process for an allegation of abuse included interviewing the resident, assessing the resident for injury, ensuring the resident is safe, interviewing staff, documenting in the Initial Event Documentation or the progress notes, and notifying the DON to determine if it was a FRI (Facility Reportable Incident). When asked about the EWR completed by LPN/UM #3 for CNA #8, LPN/UM #3 stated she was the supervisor on 07/31/22 when Resident #134 stated CNA #8 was rough with [him/her]. LPN/UM #3 further stated that she assessed the resident's body due to a complaint that CNA #8 rubbed [him/her] too hard with care, but that there were no skin issues, complaints of pain, or change in range of motion. LPN/UM #3 then stated she notified the DON that same day and completed the EWR for CNA #8. She also stated that when she interviewed Resident #134 the following day, the resident was unable to recall the allegation.
During an interview with the surveyor on 09/06/22 at 1:56 PM, the ICP explained the process for an allegation of abuse included completing an investigation, collecting statements, and notifying the NJDOH within two hours. When asked about the abuse allegation made by Resident #134, the ICP stated that she was performing rounds when she happened to walk up on the conversation between Resident #134 and CNA #8. The ICP stated that the CNA was speaking unprofessionally to the resident and that the ICP spoke to CNA #8 about professionalism. When asked if the ICP was present in the Resident #134's room the entire time CNA #8 was performing care, the ICP stated CNA #8 was already in the room when she entered and that she did not witness the care performed by the CNA in its entirety.
During a telephone interview with the surveyor on 09/08/22 at 10:35 AM, CNA #8 stated that on the day of Resident #134's allegation, she was sent home and allowed to return to work two days later. The CNA stated the alleged incident did not occur and was unaware of the results of the investigation.
During a telephone interview with the surveyor on 09/08/22 at 11:22 AM, the Agency Nurse assigned to Resident #134 on 07/31/22 stated that she entered Resident #134's room and the resident was crying. When the Agency Nurse asked if the resident was going to eat [his/her] meal, the resident stated [he/she] wanted to speak to a supervisor. The Agency Nurse further stated that the resident did not go into any details about the complaint, and that she notified LPN/UM #3 who was the supervisor for that shift.
During a follow-up interview with the surveyor on 09/08/22 at 12:18 PM, the ICP stated she could not recall specifically what the CNA said to the resident, but that the CNA's tone was louder than normal, and the resident perceived the CNA's speech as a rough manner.
During a follow-up interview with the surveyor on 09/09/22 at 12:15 PM, the DON explained the process for an abuse allegation included separating the involved parties, interviewing anyone present including staff and residents, obtaining written statements that are signed, assessing the resident, notifying the resident's family and physician, notifying the NJDOH within two hours, completing an investigation report, and notifying the NJDOH of the conclusion to the investigation. When asked about the abuse allegation made by Resident #134, the DON stated that she was notified of the incident on 07/31/22 and was told that the resident reported that CNA #8 was rude, aggressive, and pulled the resident's arm. The DON further stated that she instructed LPN/UM #3 to obtain statements and send CNA #8 home pending the investigation. The DON stated that the investigation included obtaining statements from the ICP and CNA #8, and that she believed a statement was obtained from the resident's roommate. The DON also stated that the resident's care plan was reviewed during the investigation. When asked about the conclusion to the allegation investigation, the DON stated she typed up a conclusion, emailed it to the NJDOH, and kept a copy in her office.
The surveyor and DON reviewed the soft file and the EMR related to Resident #134's allegation. The DON acknowledged that statements should have been obtained for the resident's nurse and roommate, and that the other statements should have been written and signed by the person providing the statement. The DON also stated the resident should have had a physical assessment completed at the time of the allegation and that it should have been documented in the resident's medical record. After reviewing the Care Plan, the DON verified the resident's Care Plan was revised on 09/06/22 by the Regional Director of Clinical Services and should have been updated within 24 hours of the allegation by the UM.
At that time, the surveyor accompanied the DON to her office to obtain a copy of the conclusion to the allegation investigation, however, the DON was unable to locate the conclusion in her office.
On 09/13/22, the facility provided a copy of a Grievance Form related to Resident #134's allegation of abuse, dated 08/01/22, which included, Resident had alleged on 07/31/22 that a CNA was rough with [him/her] while getting care. Resident stated that CNA nasty to [him/her] and [he/she] felt degraded, and was signed by LPN/UM #3. Further review of the Grievance Form included, To ensure abuse and neglect are ruled out promptly, does this grievance require further investigation? Yes.
During an interview with the surveyor on 09/13/22 at 11:31 AM, the LNHA stated he was unable to recall when he was notified of the alleged abuse between Resident #134 and CNA #8. The LNHA further stated that the DON was responsible for completing the investigation, but he was unable to recall when the results of the investigation were reported to him.
Review of the facility's Abuse policy, revised 02/2022, included, Allegations/reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management, and Initiate the investigative process. Refer to the 'Investigation - How to Conduct' Protocol. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interviewable and have information regarding the allegation. The policy also included, Conclusion must include whether the allegation was substantiated or not and what information supported the decision.
Review of the facility's Investigations, How to Conduct policy, revised 11/2021, included the following:
- The investigator conducts interviews in the following order: The Resident(s) involved; Locate and arrange interviews with people involved in, or who may have witnessed, the incident (i.e. the person who found the resident .); Witnesses should be interviewed separately and all provide written statements whenever possible.
- Complete a physical assessment, identifying areas of injury.
- Complete a comprehensive record review, which may include, but not limited to, the following elements . Interdisciplinary Plan of Care
- Interview all potential witnesses . Employees, Roommates
- Summarize analysis of facts gathered that: Establish reasonable cause for the incident; Establish need for further investigation, before a reasonable cause of the incident can be established.
NJAC 8:39-4.1(a)(5)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to complete a significant change ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to complete a significant change in status (SCSA) Minimum Data Set (MDS), an assessment tool utilized to facilitate the management of care. This deficient practice was identified for 1 of 1 resident (Resident #208) reviewed for expired resident and was evidenced by the following:
Within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition, a SCSA/MDS must be completed. (For purpose of this section, a significant change is a decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)
Review of the admission Record reflected that Resident #208 was admitted to the facility with diagnoses which included, but were not limited to, malignant neoplasm (cancer) of esophagus, unspecified severe protein-calorie malnutrition, unspecified cirrhosis of liver (end-stage liver disease), multiple sclerosis (a disease that impacts the brain, spinal cord and optic nerves, which make up the central nervous system and controls everything we do), Chronic Obstructive Pulmonary Disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), and adult failure to thrive.
Review of the Physician Progress Note dated [DATE] at 3:18 PM reflected that the Chief Complaint/Nature of presenting problem was COPD with oral cancer status post chemo [chemotherapy] and radiation. The progress note further reflected under Plan which included, but was not limited to, low platelet count: monitor for bleeding, and (?)palliative care evaluation.
Review of the General Documentation progress note dated [DATE] at 2:25 PM reflected that resident had worsening labs and an over all rapid decline. The Resident had end stage liver disease and was given a three month mortality rate per the hospital. The facility attempted to set resident up with palliative care for the resident on [DATE] with a palliative care agency, with no response from the agency. The Social Worker reached out to the agency, who indicated that they do not accept resident's insurance. The facility notified the Advanced Practice Nurse (APN) of the worsening lab values, and the inability to have resident assessed for palliative care today. The APN gave a new order to send Resident #208 to the emergency room. Resident's family was notified, and requested resident be sent to a specific hospital and to hold off on transfer until she arrives to facility.
Review of General Documentation progress note dated [DATE] at 3:44 PM reflected that Resident's mother arrived to the facility and met with the Unit Manager, Director of Nursing (DON) and the Social Worker, stating that resident is tired of going to the hospital and would not want to go. The Resident's code status was changed to Do Not Resuscitate (DNR), Do Not Intubate (DNI), and to continue tube feeds as prescribed. The facility consulted a hospice company and hospice was on the way to evaluate resident for the treatment of end stage liver disease.
Review of Social Services Documentation progress note dated [DATE] at 8:37 PM reflected that the Team met with resident's mother this afternoon as resident was showing a rapid decline due to [his/her] end stage liver disease. Team discussed options as far as palliative care, hospice care and going to the hospital. Resident had been a full code but mother stated that resident has said he/she wouldn't want to go back to the hospital and doesn't want to die at the hospital. Decision was made to keep resident at facility and have him/her evaluated by a hospice agency for possible inpatient hospice care at our facility. An end of life planning form was also completed with orders for DNR, DNI, DNH (do not hospitalize). The hospice agency sent their nurse right out to evaluate resident] but resident doesn't meet the criteria at this time for general inpatient care. Emotional support was provided to the resident and mother. The Social Worker to remain available as needed for additional support.
Review of the facility's Electronic Medical Record (EMR) under the tab MDS reflected that the following MDS assessments were completed for Resident #208: an Entry MDS, an admission MDS, a Medicare 5-Day MDS, and a Death in Facility MDS. The EMR did not reflect that a SCSA MDS was completed when the Team identified that the resident significantly declined as evidenced in the progress notes on [DATE].
During an interview with the surveyor on [DATE] at 11:53 AM, the MDS Coordinator Registered Nurse (MDSRN) #2 stated that she completed Resident #208's MDS assessments. MDSRN #2, in the presence of the surveyor, reviewed Resident #208's progress notes. MDSRN #2 stated, I remember this resident was not doing well when the resident was admitted ; and I remember the resident was declining. MDSRN #2 further stated that Resident #208 was supposed to be admitted to hospice but never was because of his/her insurance. MDSRN #2 stated, I think we wanted to do a significant change MDS, we talked about the resident going on hospice and we waited to see if the resident went on hospice. We waited and waited and resident never went on hospice but was evaluated. We figured the resident would go on hospice after a while and the resident declined. The MDSRN #2 stated that in retrospect, when I read all of the progress notes, I should have done a significant change MDS as the progress notes clearly indicate the resident was declining and I should have completed the significant change MDS. MDSRN #2 stated that a significant change MDS was completed when a resident goes on hospice or within two weeks of when the resident declined.
During an interview with the surveyor on [DATE] at 12:09 PM, the Director of Nursing stated that her expectation was that the MDS Coordinator would have completed the significant change MDS and it was important to complete this MDS to continue the resident's plan of care.
During the Exit Conference on [DATE], in the presence of the survey team, the Licensed Nursing Home Administrator stated that the facility had 14 days to determine if the resident had a decline and another 14 days to complete the significant change MDS.
Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, [DATE], reflected on page 2-18 that a SCSA MDS must be completed no later than the 4th calendar day after determination that a significant change in resident's status occurred. The manual further reflected on page 2-22 that A significant change is a major decline or improvement in a resident's status.
NJAC 8:39-11.2(i)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to a.) follow a physician's order...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to a.) follow a physician's order for bilateral side rail pads for one resident, 1 of 6 residents (Resident #6) reviewed for accidents.
The deficient practice was evidenced by the following:
During tour of the 2B unit on 08/30/22 at 11:14 AM, the surveyor observed Resident #6 in bed with the head of bed (HOB) and bilateral half side rails elevated. The surveyor observed that Resident #6 was leaning to the right side and there was no padding to either side rail. When interviewed, Resident #6 was unable to provide any information about his/her care.
According to the admission Record, Resident #6 was admitted with diagnoses that included, but were not limited to, senile degeneration of brain, hemiplegia (paralysis of one side of the body) and muscle weakness.
Review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/14/2022, revealed staff identified Resident #6 as severely cognitively impaired, had no behaviors, required total assist of one staff for bed mobility and dressing and was at risk of developing pressure ulcers/injuries.
Review of Resident #6's 12/07/21 Full QA Report (incident report) provided by the Director of Nursing (DON) revealed the resident had a skin tear to back of left upper arm that was found by the Certified Nurse Assistant (CNA) while dressing the resident. The incident report indicated under the Actions section that the Care Plan (CP) was updated, first aid was initiated, long sleeves/Geri sleeves applied and padding on bed/equipment.
Review of the Order Summary Report for active orders as of 09/08/22 revealed an 12/07/21 physician order (PO) for side rail pads in place for prevention every shift for wound prevention.
Review of the CP included a focus, initiated on 01/26/22, that Resident #6 was at risk for impaired skin integrity related to fragile skin. The CP also included a focus, initiated on 02/20/17, that Resident #6 used side rail for increased independence and mobility. The surveyor observed that Resident 6's CP did not include documentation of Resident #6's side rail pads.
Review of the Visual/Bedside [NAME] report did not include documentation of Resident #6's side rail pads.
On 09/06/22 at 09:21 AM, the surveyor observed Resident #6 resting in bed. The surveyor observed that there was no padding applied to the resident's side rails while in bed. The surveyor made the same observation on 09/08/22 at 10:30 AM.
During an interview with the surveyor on 09/08/22 at 10:31 AM, the Hospice Certified Nurse Assistant (Hospice CNA) stated that she worked at the facility since March 2022 and that the resident required total assist with care. When questioned about the side rail pads, the Hospice CNA stated that Resident #6 did not have padding to side rails.
During an interview with the surveyor on 09/08/22 at 10:49 AM, the Registered Nurse/Unit Manager (RN/UM) stated Resident #6 was totally dependent on staff for care, had no wounds, and that the resident had a history of sustaining skin tears. The RN/UM added that interventions included geri-sleeves to extremities and that the resident's side rails were padded. The RN/UM stated the resident normally had blue padding applied to side rails and it was the nurses' responsibility to make sure they were in place. The surveyor requested the RN/UM to accompany the surveyor to the resident's room. At which time, the RN/UM confirmed that the resident did not have padding to the siderails and stated that the resident had them on at one point in time. The RN/UM was unable to locate side rail pads in the resident's room and stated that no one had informed her that the pads were missing. The RN/UM further stated she did not know how long the side rail pads were not in place.
Review of the August 2022 and September 2022 Treatment Administration Record (TAR) revealed the aforementioned PO with the administration times of 7:00 AM, 3:00 PM, and 11 PM. The TAR further revealed that nurses signed daily that the side rail pads were in place.
During an interview with the surveyor on 09/09/22 at 12:41 PM, the Director of Nursing (DON) stated that she expected the side rail pads to be in the resident's room and available.
During an interview with the surveyor on 09/13/22 at 11:19 AM, the Regional Director of Clinical Services stated that Resident #6's side rail pads should have been applied per the physician order and that the nurses should not have been signing the side rail pads as completed on the TAR if they were not applied as ordered.
NJAC 8:39-27.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure that a resident with an indwelling urinary catheter (tub...
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Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to ensure that a resident with an indwelling urinary catheter (tube inserted into the bladder to facilitate the flow of urine) had physician orders for the care of the catheter. The deficient practice was identified for 1 of 2 residents (Resident #136) reviewed for catheters.
This deficient practice was evidenced by the following:
On 08/30/22 at 10:27 AM, during the initial tour of the 1st floor, the surveyor observed Resident #136 in bed. At that time, the surveyor observed a urinary catheter drainage bag attached to the bed frame. The catheter drainage bag was also observed on 08/31/22 and 09/01/22.
A review of Resident #136's electronic medical record (EMAR) under Diagnosis revealed a diagnosis of but not limited to, Neuromuscular Dysfunction of the Bladder (lack of bladder control due to brain, spinal cord or nerve problems).
A review of Resident #136's most recent Minimal Data Set, an assessment tool, dated 07/28/22, revealed Resident #136 had an indwelling catheter.
A Review of Resident's #136's physician's orders located in the EMAR, did not reveal any orders for care of the suprapubic urinary catheter (tube inserted through the pelvic region to maintain the flow of urine).
A Review of Resident #136's Care Plan, with an initiation date of 07/25/22, revealed Resident #136 had bladder incontinence. The Care Plan further revealed Resident #136 had a suprapubic, indwelling catheter.
On 09/01/22 at 10:04 AM, during an interview with the surveyor, Resident #136 stated his catheter needs to be changed but the nurse cannot do it since it is a suprapubic catheter.
On 09/07/22 at 10:02 AM, during an interview with the surveyor, Licensed Practical Nurse/Unit Manager (LPN /UM) #1 confirmed Resident #136 had a suprapubic catheter. LPN/UM #1 stated We changed it yesterday when asked if there are any orders for the catheter. LPN/UM #1 confirmed Resident #136 needed to have physician's orders for catheter care. LPN/UM #1 said Other than me not finishing his chart check. in response to being asked if there was a reason the resident did not have physician orders.
On 09/12/22 at 1:27 PM, during an interview with the surveyor, the Director of Nursing stated, Orders to check, to make sure there is no leakage, signs and symptoms of infection, the type, when it needs to be changed, and a diagnosis in response to being asked what the expectation is for the medical record when someone is admitted with a urinary catheter.
A review of a facility policy titled, Physician Orders created on 1/2021 revealed under Policy that, It is the policy of this facility to secure physician orders for care and services for residents as required by state and federal law . Further, the policy revealed under Procedure number 8, that Licensed Nurse receiving/accepted order is required to transcribe the order to the MAR or EMAR containing all required information.
N.J.A.C. 8:39-27.1
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of other facility documentation, it was determined that the facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to implement infection control measures for the handling and storage of respiratory equipment for 2 of 4 residents reviewed for respiratory care, (Resident # 10 and Resident # 180). This deficient practice was evidenced by the following:
1. On 09/06/22 at 12:29 PM, Surveyor #1 observed the mouthpiece, chamber, and tubing of Resident #10's nebulizer propped in an upright position by the machine. The mouthpiece, chamber, and tubing was not contained in a bag and was exposed to the surrounding environment. A nebulizer machine delivers aerosol medication to the person via a mouthpiece and chamber/cup that holds the medication, via tubing that is attached to the machine. It is used to treat respiratory conditions such as COPD, bronchitis, asthma etc.
On 09/08/22 at 8:04 AM, Surveyor #1 observed the mouthpiece, chamber and tubing of Resident #10's nebulizer draped over the nebulizer machine. The mouthpiece, chamber, and tubing was not contained in a bag and exposed to the surrounding environment.
On 09/07/22 at 10:56 AM, Surveyor #1 observed the mouthpiece, chamber and tubing of the Resident #10's nebulizer draped over the nebulizer machine. The mouthpiece, chamber, and tubing was not contained in a bag and exposed to the surrounding environment.
According to the admission record, Resident #10 was admitted to the facility with diagnosis, including but not limited to; Chronic Obstructive Pulmonary Disease, and Shortness of Breath.
A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate residents care, dated 08/18/22, revealed a Brief Interview for Mental Status (BIMS) as a 15/15 which indicated Resident # 10 was cognitively intact. The MDS also revealed the use of oxygen within the past 14 days.
A review of the current Order Summary Report revealed a physician's order for Albuterol Sulfate Nebulization Solution (a bronchodilator, medication that relaxes the muscles in the lungs making it easier to breathe) 2.5 mg (milligrams)/3 ml (milliliters) inhale orally via nebulizer every 4 hours as needed for shortness of breath/wheezing.
During an interview with the surveyor on 09/07/22 at 11:50 AM, the Registered Nurse (RN #2) confirmed that nebulizers are to be stored in bags.
During an interview with the surveyor on 09/12/22 at 10:15 AM, the Licensed Practical Nurse Unit Manager (LPN/UM #3) confirmed that nebulizers are to be stored within a bag. When asked if the nebulizers are to be stored either uncovered hanging over the machine or upright on the machine, LPN/UM #3 stated, no it is not.
2. On 09/01/22 at 1:25 PM, the surveyor observed an oxygen (O2) concentrator in Resident # 180's room. The oxygen was not in use and the tubing was observed on top of the concentrator and nasal cannula portion was lying on the windowsill exposed and uncovered.
On 09/06/22 at 9:04 AM, the surveyor observed Resident #180's O2 concentrator. The tubing was observed on the windowsill with the nasal cannula in contact with windowsill exposed and uncovered.
According to the admission Record Resident # 180 was admitted to the facility with diagnosis including but not limited to: Chronic Obstructive Pulmonary Disease.
A review of the most recent MDS dated [DATE] revealed a BIMS score of 15/15 indicating the Resident is cognitively intact. The MDS further revealed the resident used oxygen in the past 14 days.
A review of the Order Summary Report with active orders as of 09/08/22 revealed a physician's order for Oxygen via NC (nasal cannula) 2 liters per minute continuous every shift for monitoring.
During an interview with the surveyor on 09/09/22 at 9:54 AM, LPN #3 said the process for oxygen tubing is change every other day on the 11 PM-7 AM shift and when not in use the tubing is supposed to be stored in plastic bag with date on it.
During an interview with the surveyor on 09/09/22 at 9:58 AM, LPN/UM #2 said oxygen tubing is replaced every week 11 PM-7 AM shift on Sundays. She went on to say the nurses should date tubing and the bag with name and date on it. LPN/UM #2 further stated oxygen tubing should be in bag when not in use.
During an interview with Director of Nursing (DON) on 09/12/22 at 10:45 AM, the DON said that the expectation of oxygen tubing and/or nebulizers is that they will be in the resident's room in a bag.
The facility was not able to provide a policy regarding Respiratory Equipment storage when not in use.
NJAC 8:39-25.2(b)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to obtain a physician order to monitor the dialysis access site an...
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Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to obtain a physician order to monitor the dialysis access site and failed to ensure the dialysis transfer forms of ongoing records of communication between the facility and dialysis center were consistently completed for 1 of 1 resident reviewed for dialysis care, (Resident #119). This deficient practice was evidenced by the following:
During an interview with the surveyor on 09/06/22 at 9:21 AM, Resident #119 said he/she goes to dialysis on Monday-Wednesday-Friday (MWF). Resident #199 went on to say that he/she gets dialysis through a catheter in right chest as the shunt is not ready for use.
According to the admission record Resident #119 was admitted to the facility with diagnoses, including but not limited to, infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, End Stage Renal Disease, and dependence on renal dialysis.
A review of the most recent Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/14/22 revealed a Brief Interview for Mental Status score of 15/15 indicating Resident #119 was cognitively intact. The MDS further revealed the resident received dialysis while a resident.
A review of the current Order Summary Report with Active Orders as of 08/01/22 revealed a physician order for the Resident to attend dialysis 3 times a week on (MWF) with a pickup time at 10:30 for a chair time of 4 hrs one time a day every Mon, Wed, Fri for Dialysis. A further review of the Order Summary Report did not include physician orders for care or monitoring of the shunt and catheter used for dialysis access.
A review of the Medication Administration Records for August 2022 and September 2022 did not include documentation of care or monitoring of the shunt and catheter for dialysis access.
A review of the Care plan for Resident #119 revealed a focus area of the resident needs dialysis related to End Stage Renal Disease with an initiated date of 11/24/21. Under the interventions/task section revealed monitor and document/report to physician as needed any signs/symptoms of infection to access site: redness, swelling, warmth or drainage. The care plan further indicated Monitor/document/report to MD as needed for signs/symptoms of the following: bleeding, hemorrhage, bacteremia, septic shock.
A review of Resident #119 Dialysis Transfer/Communication Form revealed missing documentation for the following dates: 08/05/22 from nursing, 08/12/22 from nursing and dialysis, 08/17/22 from dialysis, 08/26/22 from nursing and dialysis, 09/02/22 from nursing and dialysis, 09/04/22 from nursing and dialysis, and 09/07/22 from nursing.
During an interview with the surveyor on 09/08/22 at 9:04 AM, Licensed Practical Nurse (LPN #1) stated we check to make sure there is no leakage on the bandage after dialysis return or before he/she leaves depending on time of departure. We document once resident returns.
During an interview with the surveyor on 9/08/22 at 9:35 AM, RN/UM stated we make sure the site is not bleeding and not infected. For a fistula check bruit and thrill (When you slide your fingertips over the site you should feel a gentle vibration, which is called a thrill. Another sign is when listening with a stethoscope a loud swishing noise will be heard called a bruit.) every shift. When asked about a perma cath (catheter placed in the chest wall for dialysis access) she replied I don't think we do anything but monitor those. We have pre dialysis and post dialysis assessments they (nurses) do and there should be physician order for the monitoring of fistula or perma cath.
On 09/08/22 at 9:40 AM, the surveyor and the RN/UM reviewed the Order Summary Report for Resident #119. The RN/UM acknowledged there were no physician's orders to monitor the fistula and the perma cath. The RN/UM stated the physician's order only included dialysis. RN/UM went on to say it is important that the shunt gets monitored so we know the device is working correctly and not clogged and perma cath because if bleeding have to put pressure on and call 911. The resident has both a fistula and perma cath and should be monitored.
During an interview with the surveyor on 09/12/22 at 1:07 PM, the Director of Nursing (DON) said yes, the expectation is to have care/monitoring of dialysis site. We usually check bruit and thrill every shift. Check site and remove bandage and monitor for bleeding every shift. Perma cath is monitored for bleeding every shift. The DON further said yes, there should be physician's order and the physician's order would be documented on the TAR (Treatment Administration Record). The DON said a communication book with separate sheet for each dialysis treatment is when he/she attends dialysis. The DON stated it is the Unit Manager or the Supervisor's responsibility to ensure the communication book is sent with the resident to dialysis and reviewed for completeness upon the resident's return.
A review of a facility policy titled Dialysis Management with last revised date of 5/2022 revealed under the Procedure section:
1. on admission resident will be assessed to determined access type; AV (Arterial Venous) fistula/AV Graft/Central catheter. Site will be observed for function and signs and symptoms of infection.
2. The nurse will obtain orders for monitoring of site and interventions as appropriate. Orders to include:
observe shunt for s/s of infection/inflammation. observe for thrills, bruits and every shift; report any abnormal findings to physician and/or dialysis.
Observe perma cath/central catheter for bleeding and placement q (every) shift. if dislodged apply pressure and call 911.
4. Facility will establish open communication with the resident's dialysis center utilizing a Dialysis Communication Book completing the Dialysis Communication Form (CD-3A)
a. The nurse will establish pre-dialysis vital signs, (blood pressure, pulse temperature, respirations)
b. Advanced Directive status
c. any pertinent resident information.
5. On return from the Dialysis Center the nurse will review the communication returning from Dialysis Center. The nurse should review specifically, pre and post vital signs, treatment tolerance, any meds (medications) giving [given] and any new orders for resident care.
N.J.A.C. 8:39-27.1(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to supervise the administration of medication for 1 of 10 residents (...
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Based on observation, interview, record review, and review of other facility documents, it was determined that the facility failed to supervise the administration of medication for 1 of 10 residents (Resident #19) reviewed for medications.
This deficient practice was evidenced by the following:
On 09/06/22 at 9:50 AM, the surveyor observed Resident #19 lying in bed. There was a medicine cup with pills in it on the resident's over-the-bed table. When asked about the medicine cup, the resident stated the nurse left the medication at the bedside because the resident was waiting for his/her breakfast tray before taking the medications.
During an interview with the surveyor on 09/06/22 at 9:51 AM, Licensed Practical Nurse (LPN) #3 stated she completed the morning medication pass for her assignment. She further stated that the medication administration process included making sure the resident swallowed their medications before leaving the resident's room because sometimes they can choke, or drop the medication, and that medication should not be left with the resident. When asked about Resident #19's medication that was left at the bedside, LPN #3 stated she should have waited until the resident's breakfast tray was delivered before administering the medications.
During an interview with the surveyor on 09/06/22 at 10:00 AM, the Registered Nurse/Unit Manager (RN/UM) stated the nurse administering medications should watch the resident take their medications because the resident could pocket their medication in their cheeks, choke on the medication, or drop the medication. The RN/UM explained that if the Medication Administration Record (MAR) showed the nurse's initials and a check mark, it meant the medication was signed as administered. The RN/UM further stated that if the resident refused to take their medication, the nurse should take back the medications and re-attempt to administer the medications later. The RN/UM then stated that there were no residents on her unit that were allowed to self-administer medications.
At that time, the surveyor accompanied the RN/UM to Resident #19's room. The RN/UM acknowledged the medications were left at the bedside but was unable to identify the quantity or what specific pills were in the medicine cup. The RN/UM then took the medicine cup out of the room and gave it to LPN #3. The RN/UM stated that LPN #3 should have taken the medications back and reoffered the medications to the resident when the breakfast tray was delivered. The RN/UM reviewed Resident #19's MAR and verified that the morning medications were signed out as administered and stated that LPN #3 should have documented the medications as refused.
According to the admission Record, Resident #19 was admitted with diagnoses which included, but were not limited to, dementia with behavioral disturbance.
Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 05/23/22, revealed the resident had a Brief Interview for Mental Status of 13 which indicated that the resident's cognition was intact.
Review of the Care Plan included a focus of Impaired cognitive function or thought process R/T [related to] Dementia, dated 12/01/19, and an intervention to Administer medications as ordered. Further review of the care plan did not include that the resident was able to self-administer medications.
Review of the Order Summary Report, dated 09/06/22, did not include an order that the resident was able to self-administer medications.
Review of the September 2022 MAR revealed the following medications were signed as administered for the morning medication pass:
1. Paroxetine 20 mg (milligrams) 2 tablets by mouth one time a day for depression
2. Buspirone 10 mg 1 tablet by mouth three times a day for anxiety
3. Aripiprazole 5 mg 1 tablet by mouth one time a day for Major Depressive Disorder with psychotic symptoms
4. Metoprolol Tartrate 100 mg 1 tablet by mouth two times a day for hypertension
5. Furosemide 20 mg 3 tablets by mouth one time a day for edema
6. Anastrozole 1 mg 1 tablet by mouth one time a day for carcinoma (organ tissue cancer)
7. Biotin (Vitamin B7) 5 mg 1 tablet by mouth one time a day for supplement
8. Gabapentin 300 mg 1 capsule by mouth one time a day for neuropathy
9. Oxybutynin Chloride 5 mg 1 tablet by mouth two times a day for urinary spasms
10. Potassium Chloride Extended Release 20 MEQ (milliequivalents) 1 tablet by mouth two times a day for muscle weakness
During an interview with the surveyor on 09/06/22 at 10:56 AM, the Director of Nursing (DON) stated that the nurse should monitor the resident while they take their medications for resident safety. The DON further stated that if the resident refused to take their medication at that time, the nurse should remove the medications and reapproach the resident later. When the surveyor informed the DON of the above observation of Resident #19's medications that were left at the bedside, the DON stated that LPN #3 should have taken the medications out of the resident's room and should not have signed the medications as administered.
Review of the facility's Medication Administration policy, revised 12/2021, included, For residents not in their rooms or otherwise unavailable to receive medications on the pass, the MAR may be 'flagged.' After completing the medication pass, the nurse returns to the missed resident to administer the medication, and, If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. Further review of the policy included, Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.
NJAC 8:39-27.1(a); 29.2 (d)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure expired and discontinue...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to ensure expired and discontinued medications were removed from active inventory and medications were appropriately labeled and dated when opened in 1 of 4 medication carts reviewed. This deficient practice was evidenced by the following:
On [DATE] at 11:40 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #2), observed the following within the 2C Wing medication cart:
-One opened box of Insulin Lispro (Humalog) 100 unit/milliliter (ml) located inside a plastic bag for Resident #12. The box was labeled with an opened date of [DATE]. At that time LPN #2 stated that Resident #12 only received insulin when needed because he/she was on a sliding scale (received insulin depending on the blood sugar level) and that insulin had an expiration date of 30 days once opened.
-Incruse Ellipta Aerosol Powder Inhalation Powder 62.5 micrograms (mcg) (used to treat asthma or Chronic Obstructive Pulmonary Disease-COPD) for Resident #131 labeled with an opened date of [DATE]. LPN #2 stated I think this medicine was discontinued and Resident #131 does not get this medicine anymore.
-One opened and undated box of Fluticasone Propionate HFA (Flovent HFA)110 microgram (mcg) (used to treat asthma) for Resident #41. LPN #2 stated that the inhaler should have been dated at the time the inhaler medication was opened.
Review of Resident #12's August and [DATE] Medication Administration Report (MAR) revealed a physician's order (PO), dated [DATE], for Humalog Solution 100 unit/ml (insulin Lispro-human) inject 5 units subcutaneously before meals for diabetes.
Review of Resident #131's [DATE] MAR revealed that Incruse Ellipta Aerosol Powder 62.5 mcg was discontinued on [DATE].
Review of Resident #41's [DATE] MAR revealed a PO, dated [DATE], for Flovent HFA Inhalation Aerosol 110 mcg, 1 puff inhaled orally every morning and at bedtime for COPD.
During a follow up interview with the surveyor on [DATE] at 12:44 PM, LPN #2 stated that the Humalog insulin was expired, should have been discarded, and a new insulin should have been ordered for Resident #12. LPN #2 further stated that the Ellipta inhaler should have been removed from the cart when it was discontinued, and the Flovent Inhaler should have been dated when opened.
During an interview with the surveyor on [DATE] at 11:42 PM, LPN #3 stated that when a nurse opened a new medication such as an insulin or an inhaler, the nurse would write the date the medication was opened on the medication package. LPN #3 further stated that discontinued medications should not be kept in the medication cart and that Humalog insulin had an expiration date of 28 days after opened.
During an interview with the surveyor on [DATE] at 12:44 PM, the Director of Nursing (DON) stated that when a medication such as insulin or an inhaler was opened, the nurse would immediately write the date it was opened on the medication. The DON stated that Humalog insulin had an expiration date of 28 days after opened and that the Humalog insulin for Resident #12 was expired, and should have been discarded. The DON further stated that expired and discontinued medications should be removed from the medications carts and placed in the medication storage rooms to be returned to pharmacy.
A review of the facility's policy titled Medication Storage, revised 10/2021, revealed that expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy.
On [DATE] at 12:18 PM, the Assistant Administrator stated that the facility did not have any other policies for labeling, dating, and storing of medications.
NJAC 8:39-29.4(g)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently serve foods at a safe and appetizing temperature. ...
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Based on observation, interview, record review and review of other facility documentation, it was determined that the facility failed to consistently serve foods at a safe and appetizing temperature. This deficient practice was evidenced by the following:
Cross Reference F 802
On 08/30/22 at approximately 10:05 AM, the surveyor conducted the initial tour of the kitchen. The surveyor questioned the Director of Food Services (DOFS) why the kitchen staff were still assembling breakfast trays at 10:00 AM. The DOFS explained, We are normally done breakfast tray line by 9 AM. I had to call in (2) staff who were scheduled off today and borrow a cook from our sister facility. Staffing has been an issue for the month I've been here. It is slowing and affecting our production.
On 09/01/22 at 10:22 AM, the surveyor conducted an interview with the DOFS to determine why the breakfast trays were late to arrive on the 2-C unit, as per the meal delivery schedule provided to the surveyor on entrance. The surveyor questioned the DOFS if trays had arrived late because the kitchen was short of staff, as previously told to the surveyor on the initial kitchen tour. The DOFS responded, Yes we are short of staff today. The trays arrived on the 2-C unit late because I don't have enough staff. I would say this is an industry wide problem. I am also short cooks. I have 5 people in orientation right now. I have made the administrator aware. He told me to look at a job search engine. The surveyor then asked the DOFS why some residents received trays with only a top pellet cover and no bottom pellet cover and why the hot cereal was served in a Styrofoam take out style container. The DOFS responded, We are short on pellets, yes. I also ran out of plastic lids that is why we had to use the Styrofoam containers for the hot cereals. I don't have plastic lids for the bowls. The surveyor questioned who was responsible for placing the food service orders. The DOFS explained I am responsible for the ordering, and I admit that I messed up. I've got an order coming in later today. The surveyor questioned the DOFS why the use of a top and bottom pellet is important in food service and the DOFS responded, The pellets are necessary to keep the food warm.
On 09/02/22 at 10:57 AM, the surveyor conducted an interview with the DOFS. The surveyor questioned the DOFSA why some resident's (Resident #92 was observed at breakfast in room) received their breakfast meal on a paper plate. The DOFS responded, It's not a lack of plates, it's a lack of staff. The DOFS explained that he didn't have sufficient staff and all the dishes were not cleaned. Therefore, they utilized paper plates at the breakfast meal because there was not enough regular dishware to serve all the residents' breakfast in the facility.
On 09/08/22 the surveyor at approximately 09:41 AM, the surveyor entered the kitchen to conduct a test tray to evaluate food temperatures. The surveyor had previously entered the kitchen at 07:24 AM and took tray line temperatures of the breakfast meal and observed dietary staff assembling trays with hot cereal, milks, juices, and coffee at 08:08 AM. Hot cereals were being boxed in Styrofoam at 07:24 AM as the surveyor arrived in kitchen. As of 08:09 AM the breakfast line had not been initiated for resident meal service. The breakfast tray line was initiated at 08:15 AM with 1 cook and 3 dietary staff. The surveyor selected the 2nd Floor C Cart 2 to conduct the test tray, as the meal delivery schedule designated this cart as the last cart to be delivered for the lunch meal service. The surveyor requested the dietary staff to assemble a test tray and the test tray was loaded on the 2-C Cart 2 and left the kitchen at 09:49 AM. The surveyor was accompanied by the Assistant Director of Food Service (ADOFS) and the 2-C meal cart arrived on the C-unit at 09:52 AM. Certified Nursing Staff were observed to distribute trays at 09:54 AM to the 2-C unit. The last tray on the 2-C unit meal cart was delivered at 10:01 AM. At that point the surveyor requested that the ADOFS remove the test tray from the meal cart. The surveyor and ADOFS then walked the test tray to the nurse's station to conduct food temperatures at 10:02 AM. According to the meal delivery schedule for the facility the 2nd floor 2-C Cart 2 was to arrive on the unit at 8:45 AM. All temperatures were conducted by the ADOFS utilizing the same digital thermometer that was utilized to take food temperatures on the tray line prior to meal service, where temperatures were all deemed to be within acceptable hot and cold parameters. The following temperatures were recorded:
Oatmeal: 89.8 (F) Fahrenheit
French Toast Stick: 85.8 F
Sausage Patty: 82.8 F
Milk Whole: 50.2 F
Coffee: 158 F
The surveyor conducted an interview with the DOFS on 09/08/22 at 10:08 AM. The surveyor reviewed the temperature results of the test tray with the DOFS. Upon being made aware of the test tray temperature results the DOFS responded, Ahh geeez, they were ice cold. You know it was hot when we made it. I'm losing it across the board (temperatures). It boils down to manpower and I'm still short of staff right now. I had to call my assistant in because today was delivery day.
The surveyor reviewed the facility policy titled Food Safety-Food Handling Policy; last date revised: 09/2021. The following was revealed under the heading PROCEDURE:
1. This facility recognizes that the critical factors implicated in foodborne illness are:
a. Poor personal hygiene of food service employees.
b. Inadequate cooking and improper holding temperatures.
c. Contaminated equipment; and
d. Unsafe food sources.
2. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents.
3. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.
The surveyor reviewed the facility policy titled FOOD TEMPERATURES POLICY, last date reviewed: 2/2022. The following was revealed under the heading POLICY:
Food temperatures of cold and hot food items will be recorded on all menu items and substitutions for meal service to maintain a high level of quality assurance and to monitor potentially hazardous food temperatures as per state and federal health regulations thus ensuring that foods are provided in a safe, palatable manner.
The following was revealed under the heading PROCEDURE:
2. Meal temperatures will be recorded at the beginning of meal service to ensure proper temperatures are achieved and repeated midway through at point of service if meal service exceeds 2 hours.
The surveyor reviewed the facility pest management service invoice, dated 08/26/22. The invoice under General Comments/Instructions revealed the following by the technician on duty: While the building itself looks attractive inside the kitchen is in a very unsanitary condition. From speaking with the employees, I understand that the kitchen is currently very short handed.
NJAC 8:39-17.4 (a) 2
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and other pertinent facility documents, it was determined that the facility failed to ensure pe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and other pertinent facility documents, it was determined that the facility failed to ensure personal protective equipment (PPE) (equipment such as, but not limited to gowns, gloves, and eye protection worn to protect the wearer from the spread of infection or illness) was used appropriately and failed to ensure handwashing was performed before and after exiting and entering resident rooms that were on isolation and between changing gloves. The deficient practice was observed on 1 of 4 units on the first floor.
The deficient practice was evidenced by the following:
On 08/30/22 at 10:17 AM during the initial tour, the surveyor observed a resident room with a transmission-based precaution sign (notification sign that specific precautions must be followed prior to entering or leaving the room) that revealed, ISOLATION DROPLET/CONTACT PRECAUTIONS Everyone Must: including visitors, doctors, and staff Clean hands when entering and leaving the room, Wear mask, Wear eye protections, Gown and glove at the door .
At that time, the surveyor observed Certified Nursing Assistant (CNA) #1 in the room performing care on Resident #657. CNA #1 did not have a gown on while in the room. During an interview with the surveyor, CNA #1 stated, Oh wow! At first I was thinking it (the room) was cut off from COVID. when the surveyor referred to the transmission-precaution sign outside of the room.
On 08/31/22 at 10:32 AM, in the COVID area called the RED ZONE, the surveyor observed CNA #2 exit room [ROOM NUMBER]. room [ROOM NUMBER] also had the same transmission-based precaution sign in the doorway. At that time, CNA #2 removed the gown and gloves, then took a new gown and gloves and put them on. CNA #2 then entered room [ROOM NUMBER]. CNA #2 did not perform hand hygiene after exiting or entering the rooms or changing gloves.
On the same date at 10:57 AM, during an interview with the surveyor, CNA #2 stated, I forgot to wash my hands.
On 08/31/22 at 12:36 PM, the surveyor observed an unidentified CNA passing meal trays from room to room. The CNA had a gown on that was not tied in the back. The gown was in contact with the floor as the CNA took a tray off the cart. The CNA then entered a resident room.
On 09/12/22 at 1:27 PM, during an interview with the surveyor, the Director of Nursing (DON) stated gowns should be tied in the back.
A review of the Red Zone sign outside of the unit doorways revealed, Full PPE, N95 (fit tested) Gowns or Coveralls need to be changed between each resident and if wet soiled or damaged, and when leaving the RED ZONE.
A review of the facility Outbreak Response Plan revealed under Contact Precautions number 5 to, Wear a gown if body/clothing contact with infective material is likely. The plan further revealed under number 7. to, Wash hands before entering room and after removing gloves .
A review of the facility Outbreak Response Plan revealed under Droplet Precautions number 7 to, Wash hands before entering room and after removing PPE
N.J.A.C. 8:39-19.4(k)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 08/30/2022 at 11:05 AM, Surveyor #2 observed Resident #62 without any orthotic devices on the left or right upper extremit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 08/30/2022 at 11:05 AM, Surveyor #2 observed Resident #62 without any orthotic devices on the left or right upper extremity. On 08/31/2022 at 12:13 PM, 09/01/2022 at 10:46 AM, 12:31 PM, and 1:13 PM, Surveyor #2 observed Resident #62 without any orthotic devices on the left or right upper extremity.
Review of the medical record indicated that Resident #62 was admitted to the facility with diagnoses, which included but not limited to, traumatic brain injury, tracheostomy, aphasia, (inability to formulate speech because of damage to the brain), quadriplegia (paralysis of all four limbs).
The resident's most recent annual MDS, dated [DATE], reflected Resident #62 was identified as being in a persistent vegetative state and was non-interviewable. The MDS further indicated that Resident #62 had functional limitation in range of motion of bilateral upper and lower extremities. The MDS also revealed that Resident #62 required extensive assistance and was totally dependent on staff for activities of daily living.
Review of a physician order sheet dated 05/06/22 timed at 1:40 AM, revealed a physician order for the resident to wear bilateral palm protectors with finger separators 10:00 AM - 6:00 PM/daily with/skin checks pre and post application; with/removal for hygiene as needed.
Review of Resident's #62's electronic medical record (EMAR) did not reveal any identification in the Medication Administration Record (MAR), Treatment Administration Record (TAR), or Care Plan that the palm guards/orthotics were applied per physician orders.
During an interview with the surveyor on 09/07/22 at 11:41 AM, the Director of Rehabilitation (DOR), confirmed that the bilateral orthotics with finger protectors was not identified on the current Medication Administration Record (MAR). When asked who was responsible for applying the orthotics, the DOR responded that Resident #62 was discharged from rehabilitation in November 2020, therefore it would be the responsibility of the nursing staff to apply.
During an interview with the surveyor on 09/07/22 at 11:50 AM, Registered Nurse (RN #2) stated that she was familiar with Resident #62, but was not aware of orders to apply splints. RN #2 stated that she had never seen any orders for the application of splints to any of the residents on her wing. RN #2 further stated that the orders would not be to apply splints, but rather to check placement of splints. When asked who is responsible for updating the orders and care plans, RN #2 responded, the unit manager (UM).
During an interview with the surveyor on 09/07/22 at 12:30 PM, Licensed Practical Nurse/UM (LPN/UM #3) confirmed that she was responsible for transcribing orders/updating care plans according to the physician orders and that the nurses [do not] have the responsibility for updating the orders and care plan. When asked what the timely expectation for physician orders to be transcribed/approved, LPN/UM #3 responded 24-48 hours.
During a follow-up interview with the surveyor on 09/12/22 at 10:15 AM, LPN/UM #3 confirmed that the aides or nurses are responsible for applying splints/orthotics to residents upon discharge from rehabilitation. Upon reviewing the orders for Resident #62, LPN/UM #3 reported that the orders for orthotics were placed on hold on 09/02/22 and confirmed that the orders should have been carried out and identified on the care plan prior to the hold date.
A review of a policy titled, Care Plans-Comprehensive created on 10/2015, Last Revised on 10/2021, revealed under Policy that, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Further, the policy revealed under Procedure, number eight, letter m,The comprehensive, person-centered care plan will: [m] Enhance the optimal functioning of the resident by focusing on a rehabilitative program.
NJAC 8:39-27.1(a)
Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to consistently revise and/or update resident care plans for 2 of 38 residents (Resident #6 and Resident #62) reviewed for comprehensive care plans.
This deficient practice was evidenced by the following:
1. According to the admission Record, Resident #6 was admitted with diagnoses that included, but were not limited to, senile degeneration of brain, hemiplegia (paralysis of one side of the body) and muscle weakness.
Review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/14/2022, revealed staff identified Resident #6 as severely cognitively impaired, with no behaviors, required total assist of one staff for bed mobility and dressing and was at risk of developing pressure ulcers/injuries.
Review of an Inservice Form for Resident #6's palm protector (a type of splinting that provides a barrier between the fingers and the palm), dated 11/09/21, revealed that the therapist provided education to the nursing staff for the topic of 8-4 left palm protector/orthotic with removal for hygiene and skin checks.
Review of the Order Summary Report for active orders as of 09/08/22 revealed an 08/25/21 physician order (PO) for left palm protector to be worn 8:00 AM to 4:00 PM with removal for hygiene and skin checks.
Review of the Care Plan (CP), initiated 11/08/16, included a focus of that Resident #6 had alteration in physical function related to CVA [Cerebrovascular Accident] (stroke). The surveyor observed that Resident #6's CP did not include documentation of the palm protector.
Review of the Visual/Bedside [NAME] report did not include documentation of Resident #6's palm protector.
Review of Resident #6's 12/07/21 Full QA Report (incident report) provided by the Director of Nursing (DON) revealed the resident had a skin tear to the back of the left upper arm that was found by the Certified Nurse Assistant (CNA) while dressing the resident. The incident report indicated under the Actions section that the CP was updated, long sleeves/Geri sleeves applied and padding on bed/equipment.
Review of the Order Summary Report for active orders as of 09/08/22 revealed an 12/07/21 physician order (PO) for side rail pads in place for prevention every shift for wound prevention.
Review of the Care Plan (CP) included a focus, initiated on 01/26/22, that Resident #6 was at risk for impaired skin integrity related to fragile skin. The CP also included a focus, initiated on 02/20/17, that Resident #6 used side rail for increased independence and mobility. The surveyor observed that Resident 6's CP did not include documentation of Resident #6's side rail pads.
Review of the Visual/Bedside [NAME] report did not include documentation of Resident #6's side rail pads.
During an interview with the surveyor on 09/09/22 at 10:44 AM, the Registered Nurse/Unit Manager (RN/UM) stated that any nurse could update the CP but usually the UMs would complete any updates. The RN/UM stated intervention for falls and skin alterations, such as the use of side rails, air mattress, hand splints would be documented and updated in the CP. The RN/UM reviewed Resident #6's CP, in the presence of the surveyor, and stated that she was unable to find a CP that addressed the resident's use of the palm protector and padding to the side rails.
During an interview with the surveyor on 09/09/22 at 12:41 PM, the Director of Nursing (DON) stated that Resident #6's CP should have been updated to address the resident's use of a palm protector and pads to the side rails.
During an interview with the surveyor on 09/13/22 at 11:19 AM, the Regional Director of Clinical Services stated that Resident #6's CP should have been updated when the interventions were initiated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to consistently complete neurological evaluations (neuro checks) after unwitne...
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Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to consistently complete neurological evaluations (neuro checks) after unwitnessed falls for 1 of 6 residents (Resident #189) reviewed for accidents.
This deficient practice was evidenced by the following:
On 08/31/22 at 11:46 AM, the surveyor observed Resident #189 resting comfortably in bed with the head of bed (HOB) slightly elevated. The surveyor observed floor mats positioned on both sides of the resident's bed.
According to the admission Record, Resident #39 was admitted with diagnoses which included, but were not limited to, acute respiratory failure with hypoxia (low levels of oxygen in your body tissue) and dementia.
Review of Resident #189's Significant Change Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 07/24/22, included the resident had a Brief Interview for Mental Status of 05, which indicated that the resident's cognition was severely cognitively impaired. Further review of the MDS revealed that the resident had sustained falls in the last six months.
Review of Resident #189's Care Plan (CP) included a focus, dated 04/16/2021, that the resident was at risk for falls r/t [related to] deconditioning (a decline in physical health, strength, and fitness.) The CP also included a focus, dated 05/17/21, that the resident had an actual fall r/t [related to] immobility.
Review of Resident #189's Progress Note (PN), dated 02/27/22 at 5:27 PM, revealed a Nursing Clinical Evaluation note that the Certified Nurse Assistant (CNA) found the resident on the floor. The PN further revealed that the resident was sitting on the floor with back of head bleeding. Resident vital signs stable, no complaint of any pain besides head. Area cleaned, ABD pad [dressing] applied wrapped with gauze . NP [nurse practitioner] notified. Transportation called for pick up . for evaluation, and stitches.
Review of Resident #189's hard copy chart located at the nursing station, on 09/06/22 at 1:02 PM, revealed a 02/27/22 Neurological Assessment Sheet (neuro check sheet), with plotted dates and times from 02/27/22 at 5:15 PM to 03/02/22 11-7 shift (night). The neuro check sheet indicated that neuro checks were not completed from 02/27/22 at 7:00 PM to 02/28/22 at 2:00 AM due to the resident being at the hospital for evaluation. However, there was no documentation that neurological checks (neuro checks) were completed for the following shifts once the resident returned to the facility:
02/28/22 3:00 PM -11:00 PM (evening) and night shifts,
03/01/22 7:00 AM - 3:00 PM (day), evening, and night shifts,
03/02/22 evening and days shifts.
Review of the 02/27/22 Full QA Report (incident report), on 09/07/22 at 10:11 AM, provided by the Director of Nursing (DON), revealed a different neuro check sheet. The surveyor observed that the included neuro check sheet was completed in its entirety and had the same handwriting for all times/shifts for the entire observation period. The included neuro check sheet further revealed that neuro checks were completed for Resident #189 from 02/27/22 from 7:00 PM to 10:00 PM, while the resident was out of the facility being evaluated.
Review of the 06/16/22 and 08/13/22 incident reports, provided by the DON, also included neuro check sheets. The surveyor observed that the included neuro check sheets had the same handwriting for all times/shifts for the entire observation periods. The surveyor further observed that the 02/27/22, 06/16/22, and 08/13/22 neuro check sheets had the exact same handwriting for all the documented neuro checks throughout the observation periods.
During an interview with the surveyor on 09/08/22 at 10:37 AM, Licensed Practical Nurse (LPN #1) stated neuro checks were initiated for unwitnessed falls and that nurses would document per the instructions on the neuro-check sheet. LPN #1 added that if resident was transferred out of the facility, she would document that the resident was out of the facility or hospitalized on the neuro check sheet and would continue with the neuro check assessments upon the resident's return to the facility.
Review of the neuro check sheet indicated that neuro checks should be completed as follows:
-Every 15 minutes for one hour
-Every 20 minutes for two hours
-Every hour for two hours
-Every shift for 72 hours
During an interview with the surveyor on 09/08/22 at 10:44 AM, the Registered Nurse/Unit Manager (RN/UM) stated the nurse should assume the resident hit their head with any unwitnessed falls. The RN/UM further stated that neuro checks were started immediately and that the nurses would follow the guidelines on the neuro check sheet. The nurse would check the resident's vital signs [blood pressure, pulse, temperature, respirations], pupil response, mental status and motor response. The RN/UM added that when residents were transferred out of the facility for evaluation, the nurse would document that the resident was out of facility on the neuro check sheet and would continue the neuro checks upon the resident's return to the facility.
During an interview with the surveyor on 09/08/22 at 1:20 PM, the DON stated the nurses would follow the guidelines on the neuro check sheet when completing their assessments. The DON added that neuro checks would stop when the resident transferred out, the nurse would document that the resident was at the hospital on the neuro check sheet and continue the neuro check upon the resident's return to the facility. The DON further stated that neuro checks should not be documented as completed while the resident was out of the facility. The surveyor questioned the two different neuro check sheets, one obtained by the surveyor from the resident's chart and the neuro check sheet included in the incident report that was provided by the DON for Resident #189's 2/27/22 unwitnessed fall. The DON responded that she would have to look into it and get back to the surveyor.
During a follow-up interview with DON, on 09/09/22 at 9:01 AM, the DON stated the nurse who completed the included neuro check sheet was an agency nurse and that she attempted to call that agency nurse but did not get a response.
During a follow-up interview with DON, on 09/09/22 at 12:41 PM, the DON stated she did not know where the neuro check sheet, that was included in the incident report, came from. The DON added that neuro checks were completed for three days for an unwitnessed fall and that it was not normal practice to document that a neurological assessment was completed when the resident was not present in the facility. When questioned about the neuro check sheets having the same handwriting for the entire observation period, the DON replied that incident reports were reviewed by the Unit Manager, the Assistant Director of Nursing and herself and that no one questioned the fact that the neuro check sheets had the same nurse's handwriting for the entire observation period.
During an interview with the surveyor on 09/13/22 at 11:05 AM, in the presence of the survey team, the Regional Director of Clinical Services (RNCS) stated there was no way to go back and find more information about who completed the neuro check sheets because that nurse no longer worked at the facility. The RNCS further stated she had no idea why there was two neuro check sheets for Resident #189's 2/27/22 unwitnessed fall. When questioned about nursing continuing neuro checks after Resident #189 returned from the hospital, the RNCS stated that nursing would not continue neuro checks because the hospital wound have done a CAT scan (a scan used to obtain detailed internal images of the body) to rule out any neurological issues. The RNCS further stated staff would follow the discharge instructions and would continue neuro checks if instructed to do so in the discharge instructions. The RNCS added that neuro checks should not be documented as completed for residents who were out of the facility because the nurse would not be able to assess the resident. The RNCS further stated they were unable to determine what nurse documented neuro checks when the resident was out of the facility.
Review of Resident #189's 02/27/22 hospital discharge instructions revealed a visit date of 02/27/22 6:43 PM for a diagnosis of scalp laceration. The discharge instructions indicated that an electrocardiogram (a test that records the heart's electrical activity) was completed during the emergency department visit and included laceration care patient educations material.
During a follow up interview with the DON, on 09/13/22 at 11:30 AM, the surveyor questioned the 02/27/22, 06/16/22, and 08/13/22 neuro check sheets with exact same handwriting for all the documented neuro checks. The DON stated she did not notice that all three neuro check sheets had the same exact handwriting.
During a follow up interview with the RNCS on 09/13/22 at 12:00 PM, the surveyor questioned the 02/27/22, 06/16/22, and 08/13/22 neuro check sheets with exact same handwriting for all the documented neuro checks. The RNCS stated that they were at the point where they could not explain the handwriting being the same for all three incidents or why neuro checks were documented as completed while the resident was not in the facility.
Review of the facility's Neurological Assessments, revised on 03/2022, indicated that neurological assessments would be completed as followed:
a. Every 15 minutes' x first hour
b. Every 30 minutes' x 2 hours
c. Every hour x 2 hours
d. Every shift x 72 hours
e. Then as primary healthcare provider orders
Review of the facility's Falls Management and Prevention policy, revised 01/2021, include under the Post Fall section, to 7. obtain neurological checks per policy for any unwitnessed fall or any fall with evidence of injury to head and 13. Resident fall will be evaluated for 72 hours' post fall, including full vital signs every shift.
NJAC 8:39-29.2(d)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 08/30/22 at 11:05 AM, Surveyor #2 observed Resident #62 without any orthotic devices on left or right upper extremity. On ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 08/30/22 at 11:05 AM, Surveyor #2 observed Resident #62 without any orthotic devices on left or right upper extremity. On 08/31/22 at 12:13 PM, 09/01/22 at 10:46 AM, 12:31 PM, and 1:13 PM, Surveyor #2 observed Resident #62 without any orthotic devices on left or right upper extremity.
Review of the medical record indicated that Resident #62 was admitted to the facility with diagnoses, which included but were not limited to, traumatic brain injury, tracheostomy, aphasia, (inability to formulate speech because of damage to the brain), quadriplegia (paralysis of all four limbs).
Review of the resident's most recent Annual MDS, dated [DATE], Resident #62 was identified as being in a persistent vegetative state and was non- interviewable. The MDS further indicated that Resident #62 had functional limitation in range of motion of bilateral upper and lower extremities. The MDS also revealed that Resident #62 required extensive assistance and was totally dependent on staff for activities of daily living.
Review of a physician order sheet dated 05/06/22 timed at 01:40 AM, revealed a physician order for the resident to wear bilateral palm protectors with finger separators 10:00 AM-6:00 PM daily with skin checks pre and post application; with/removal for hygiene as needed.
Review of Resident's #62's Electronic Medical Record (EMAR) did not reveal any identification in the Medication Administration Record (MAR), Treatment Administration Record (TAR), or Care Plan that the palm guards/orthotics were applied per physician orders.
During an interview with the surveyor on 09/07/22 at 11:41 AM, the Director of Rehabilitation (DOR) confirmed that the Bilateral Orthotics with finger protectors was not identified on the current Medication Administration Record (MAR). When asked who was responsible for applying the orthotics, the DOR responded that Resident #62 was discharged from rehabilitation in November 2020, therefore it would be the responsibility of the nursing staff to apply.
During an interview with the surveyor on 09/07/22 at 11:50 AM, the Registered Nurse (RN) #2 stated that she was familiar with Resident #62, but was not aware of orders to apply splints. RN #2 stated that she has never seen any orders for application of splints to any of the residents on her wing. RN #2 further stated that the orders would not to apply splints, but rather check placement of splints. When asked who is responsible for updating orders and care plans, RN #2 responded, the unit manager (UM).
During an interview with the surveyor on 09/07/22 at 12:30 PM, the LPN/UM(LPN/UM) #3 confirmed that she was responsible for transcribing orders/updating care plans according to physician orders and that the nurses [do not] have the responsibility for updating the orders and care plan. When asked what the timely expectation for physician orders to be transcribed/approved, LPN/UM #3 responded 24-48 hours.
During an interview with the surveyor on 09/12/22 at 10:00 AM, the Certified Nursing Assistant (CNA) #5 confirmed that Resident #62 had orders for splints, but they were taken out last week because they didn't fit.
During a follow up interview with the surveyor on 09/12/22 at 10:15 AM, LPN/UM #3 confirmed that the CNAs or nurses were responsible for applying splints/orthotics to residents upon discharge from rehabilitation. Upon reviewing the orders for Resident #62, LPN/UM #3 reported that the orders for orthotics were hold on 09/02/22 and confirmed that the orders should have been carried out and identified on the care plan prior to the hold date.
A review of a facility policy titled, Physician Orders created on 1/2021 revealed under Policy that, It is the policy of this facility to secure physician orders for care and services for residents as required by state and federal law . Further, the policy revealed under Procedure number 8, that Licensed Nurse receiving/accepted order is required to transcribe the order to the MAR or electronic medical record (EMAR) containing all required information.
A review of a facility policy titled, Appliances-Sprints, Braces, Slings created on 8/2015, last revised on 4/2022, revealed under Policy is To assure all splints, braces, slings, etc. are used appropriately and cared for properly and upper and lower extremities are maintained in a functional position. Further, the policy revealed under Procedure and Nursing number one, that Ensures proper schedule for donning and doffing appliance is known by CNA staff and provides appropriately sign of task options.
NJAC 8:39-27.2(m)
Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to follow a physician's order for the application of a palm protector (a type of splinting that provides a barrier between the fingers and the palm to prevent injury to the palm from finger contracture) for 2 of 3 residents (Resident #6 and Resident #62) reviewed for positioning and mobility.
The deficient practice was evidenced by the following:
1. During tour of the 2B unit on 08/30/22 at 11:14 AM, the surveyor observed Resident #6 in bed with the head of bed (HOB) elevated. The surveyor observed that Resident #6 had limitation to the left hand and did not have on a palm protector. When interviewed, Resident #6 was unable to provide any information about his/her care. The Hospice Certified Nurse Assistant (Hospice CNA) was present in the room and stated the resident required total assistance with activities of daily living.
According to the admission Record, Resident #6 was admitted with diagnoses that included, but were not limited to, senile degeneration of brain, hemiplegia (paralysis of one side of the body) and muscle weakness.
Review of the Significant Change in Status Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/14/22, revealed staff identified Resident #6 as severely cognitively impaired, with no behaviors, required total assist of one staff for bed mobility and dressing and was at risk of developing pressure ulcers/injuries.
Review of an Inservice Form for Resident #6's palm protector, dated 11/09/21, revealed that the therapist provided education to the nursing staff for the topic of 8-4 left palm protector/orthotic with removal for hygiene and skin checks.
Review of the Order Summary Report for active orders as of 09/08/22 revealed a 08/25/21 physician order (PO) for left palm protector to be worn 8:00 AM to 4:00 PM with removal for hygiene and skin checks.
Review of the August 2022 and September 2022 Treatment Administration Record (TAR) did not include the aforementioned PO.
Review of the Care Plan (CP), initiated 11/08/16, included a focus of that Resident #6 had alteration in physical function related to CVA [Cerebrovascular Accident] (stroke). The surveyor observed that Resident #6's CP did not include documentation of the palm protector.
Review of the Visual/Bedside [NAME] report did not include documentation of Resident #6's palm protector.
On 08/31/22 at 11:37 AM, the surveyor observed Resident #6 resting in a recliner. The resident did not have on a palm protector to the left hand. The surveyor made the same observations on 08/31/22 at 1:11 PM, 09/01/22 at 9:10 AM, 09/01/22 at 01:02 PM, 09/02/22 at 9:57 AM and 09/06/22 at 12:57 PM.
On 09/06/22 at 9:21 AM, the surveyor observed Resident #6 resting in bed. The resident did not have on a palm protector to the left hand. The surveyor made the same observation on 09/08/22 at 10:30 AM.
During a follow-up interview with the surveyor on 09/08/22 at 10:31 AM, the Hospice CNA stated that she worked at the facility since March 2022 and that the resident required total assist with care. The Hospice CNA further stated that the resident had a contracture to the left hand and when the resident relaxed his/her hand, the Hospice CNA was able to clean it with a with towel. The Hospice CNA added that the resident did not have a palm protector for the left hand and that she planned on following up with the Hospice Registered Nurse to request something be placed in the resident's hand.
During an interview with the surveyor on 09/08/22 at 10:40 AM, Licensed Practical Nurse (LPN) #1 stated Resident #6 was a total assist with care and had no behaviors or wounds. LPN #1 further stated that Resident #6 previously had a splint (palm protector) to the left hand that therapy applied, and nursing would remove. LPN #1 added the therapist would provide education to the nursing staff about the application of the palm protector, nursing would sign off on the education and would then be the responsible for applying the palm protector per PO.
During an interview with the surveyor on 09/08/22 at 10:49 AM, the Registered Nurse/Unit Manager (RN/UM) stated Resident #6 was totally dependent on staff for care. The RN/UM added the resident had a palm protector for the left hand that was applied from 8:00 AM-4:00 PM daily. The RN/UM stated the nurse, or the CNA would usually apply the palm protector and that it was the nurse's responsibility to make sure it was applied per the PO. The surveyor requested the RN/UM accompany the surveyor to the resident's room. As the surveyor and the RN/UM walked down the hall, the Hospice CNA was pushing Resident #6 down the hallway in a recliner. At which time, the RN/UM confirmed that the resident did not have a palm protector applied to the left hand and stated the resident should have on the palm protector.
During an interview with the surveyor on 09/09/22 at 12:41 PM, the Director of Nursing (DON) stated that she expected the resident's palm protector to be in the room and available.
During an interview with the surveyor on 09/13/22 at 11:19 AM, the Regional Director of Clinical Services stated that Resident #6's palm protector should have been applied per the physician order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2(c). A review of Resident #182's admission Record, reflected that the resident had diagnoses, which included but were not limit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2(c). A review of Resident #182's admission Record, reflected that the resident had diagnoses, which included but were not limited to, Type 2 Diabetes Mellitus with Diabetic Neuropathy.
Review of Resident #182's most recent MDS, dated [DATE], indicated that Resident #182 had a BIMS score of 13/15 which indicated the resident was cognitively intact. A further review of the resident's MDS, Section N - Medications, reflected that the resident had received insulin injections seven out of seven days.
A review of Resident #182's Order Summary Report dated 09/08/22, reflected a physician order for the insulin medication, Humalog 100 units/ml. Inject as per sliding scale: 0-140 = 0 units; 141-180 = 2 units; 181-220 = 4 units; 221-260 = 6 units; 261-300 = 8 units; 301-350 = 10 units; 351 OR GREATER, CALL HCP (Health Care Provider), subcutaneously before meals and at bedtime for Diabetes Mellitus.
A review of the resident's MAR for the period of 09/1/22-09/30/22, reflected that on 09/08/22, two units of Insulin Lispro (Humalog) was administered at 8:21 AM for a blood sugar of 161. According to the manufacturer's specifications, Humalog should be administered within 15 minutes before a meal or immediately after.
A review of the resident's Care Plan indicated a focus area that the resident had Diabetes Mellitus and was insulin dependent. The goal of the resident's Care Plan was that the resident would demonstrate a blood glucose level within acceptable ranges. The interventions of the resident's Care Plan included to monitor for signs and symptoms of hypo/hyperglycemia, administer meds per MD orders, provide therapeutic diet as ordered, and to monitor blood glucose finger stick and pay attention to blood clotting.
On 09/08/22 at 10:35 AM, the surveyor observed the resident in his/her room. The resident was exiting the bathroom and a breakfast tray was set up, covered on a nearby table. The resident stated that his/her blood sugar was tested earlier in the morning. The resident stated that he/she had not eaten.
Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to: a.) follow professional standards of nursing practice by administering expired insulin medication and b.) ensure that insulin medication was administered to residents within an appropriate time frame according to physician's order and manufacturer specifications.
This deficient practice was identified for 4 of 35 sampled residents, (Residents #12, #93, #182 and #168) reviewed for the administration of insulin (a medication used for Diabetes) during medication administration and was evidenced by the following:
1. On 09/07/22 at 11:40 AM, the surveyor, in the presence of the Licensed Practical Nurse (LPN #2), observed within the 2C Wing medication cart, one opened box of Insulin Lispro (Humalog) 100 unit/milliliter (ml) inside a plastic bag for Resident #12. The box was labeled with an opened date of 08/02/22. At that time LPN #2 stated that Resident #12 only received insulin when needed because he/she was on a sliding scale (received insulin depending on the blood sugar level) and that insulin had an expiration date of 30 days after opened.
During an interview with the surveyor on 09/08/22 at 12:44 PM, LPN #2 stated the Humalog insulin for Resident #12 was the only insulin for this resident in the medication cart and no other Humalog insulin was on the unit for Resident #12. LPN #2 stated that she had used this Humalog insulin vial to give Resident #12's insulin doses. LPN #2 stated that the insulin was expired and should have been discarded.
According to the admission Record, Resident #12 was admitted to the facility with diagnoses which included, but were not limited to, Type 2 Diabetes Mellitus (DM) (high levels of sugar in the blood) and acquired absence of left leg above the knee and acquired absence of the right leg below the knee (amputations).
Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 08/19/22, revealed that Resident #12 had moderate cognitive impairment and had received insulin injections 7 out of 7 days during the assessment period.
Review of Resident #12's August 2022 Medication Review Report reflected a physician order, dated 08/11/22, to inject 5 ml of Humalog Solution 100 unit/ML subcutaneously before meals for diabetes.
Review of Resident #12's August and September 2022 Medication Administration Record (MAR) reflected the corresponding 08/11/22 physician order for Humalog Solution 100 unit/ML inject 5 ML before meals with an administration time of 07:30 AM, 11:30 AM, and 1630 (4:30 PM)
Further review of the August and September 2022 MAR reflected that the nurses administered the expired Humalog Insulin on the following dates:
08/30/22, 08/31/22, 09/01/22, 09/02/22, 09/03/22, 09/04/22, 09/05/22, 09/06/22, and 09/07/22.
During a follow up interview with the surveyor on 09/07/22 at 12:44 PM, LPN #2 stated that the expired Humalog insulin should have been discarded and a new insulin should have been ordered for Resident #12.
During an interview with the surveyor on 09/08/22 at 1:42 PM, LPN #3 stated that Humalog insulin has an expiration date of 28 days once opened.
During an interview with the surveyor on 09/09/22 at 12:44 PM, the Director of Nursing (DON) stated that Resident #12's Humalog insulin with an opened date of 08/02/22 had an expiration date of 28 days and should have been discarded on 08/30/22. The DON further stated the nurse should not have administered the medication because it was expired.
2(a). Review of the admission Record revealed Resident #12 was admitted to the facility with a diagnosis of Type 2 Diabetes Mellitus.
Review of the August 2022 Medication Review Report for Resident #12 revealed an order dated 08/04/22 for Humalog Solution 100 Unit/ml (Insulin Lispro-Human) inject 5 ml subcutaneously before meals for diabetes.
Review of the Quarterly MDS, dated [DATE], revealed that Resident #12 had moderate cognitive impairment and had received insulin injections 7 out of 7 days during the assessment period.
Review of Resident #12's August and September 2022 MAR reflected the corresponding 08/11/22 physician order for Humalog Solution 100 unit/ML inject 5 ML before meals with an administration time of 07:30 AM, 11:30 AM, and 1630 (4:30 PM). On 09/07/22, the MAR revealed that the 11:30 AM dose included the nurses' s initials indicating that Resident#12 received 5 units of Humalog insulin.
On 09/07/22 the MAR's Location of Administration Report revealed that the 11:30 AM Humalog insulin was administered at 10:50 AM by LPN#2 subcutaneously in the abdomen
During an interview with the surveyor on 09/07/22 at 12:45 PM, LPN #2 stated that Humalog insulin can peak(decrease blood sugar levels) around 30 minutes after administered. If Humalog insulin (fast acting insulin) was administered too early, then the resident would bottom out (have low blood sugar). LPN #2 stated I really don't know how I would give the insulin when we don't know what time the food trucks would arrive on the floor.
During an interview with the surveyor on 09/08/22 at 1:15 PM, Resident #12 stated the nurse just took my blood sugar around 10:30 AM and I received my insulin. Resident #12 stated that his/her lunch had not been delivered yet.
On 09/07/22 at 1:27 PM the surveyor observed the lunch cart for second floor C wing arrive to the unit.
On 09/07/22 at 1:31 PM the surveyor observed Resident #12 received his lunch tray.
During an interview with the surveyor on 09/07/22 at 3:05 PM, LPN #2 stated that when insulin is ordered before meals, the insulin needs to be given 30 minutes before each meal.
The surveyor, in the presence of LPN #2, reviewed Resident #12's MAR Location of admission Record, and LPN #2 confirmed that the 11:30 AM insulin was documented as administered at 10:50 AM.
During an interview with the surveyor on 09/07/22, the Licensed Practical Nurse/Unit Manager(LPN/UM #2) stated that if insulin was ordered before meals, then the insulin should be administered 30 minutes before meals. It may depend on when the meal trays arrive to the floor because sometimes the meal trays are late. When the meal cart would arrive to the unit hallway, then the insulin should be given.
2(d). Review of the admission Record reflected that Resident #168 was admitted with a diagnosis of Type 2 Diabetes Mellitus.
Review of a Medication Review Report dated 09/09/22 revealed an order for Insulin Lispro (a fast-acting mealtime insulin for diabetes) 100 Unit/ML solution pen injector. Inject five units subcutaneously with meals for DM.
The Medication Review Report further reflected an order for Insulin Lispro 100 unit/ml solution pen injector. Inject per sliding scale: if 0-150 = 0; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units: 301-350 = 8 units; 351-400 = 10 units. If bs is < 400 or >70, call MD, subcutaneously before meals for DM.
Review of the most recent MDS revealed a BIMS score of 05/15 indicating Resident #168 had severe cognitive impairment.
Review of the MAR dated 09/01/22-09/30/22 reflected that the Lispro insulin order, with meals for DM, was plotted for administration at 7:30 AM, 11:30 AM and 1630 (4:30 PM). On 09/08/22 the MAR revealed that at 7:30 AM, the nurse recorded her initials, indicating that Resident #168 received 5 units of Insulin Lispro.
The MAR further revealed the sliding scale Lispro insulin order was plotted for administration at 7:30 AM, 11:30 AM, and 1630 (4:30 PM). On 09/08/2022, the MAR revealed that at 7:30 AM, the nurse recorded a blood sugar of 169, the nurse's initials and 2 units, indicating Resident #168 received 2 units of Lispro insulin.
Review of the Location of Administration Report dated 09/01/22-09/30/22 revealed that 09/08/22, LPN #1 documented that Resident #168 received his/her insulin at 7:27 AM and 7:28 AM.
On 09/08/22, the surveyor observed that Resident #168's breakfast tray arrived on the unit at 9:05 AM.
During an interview with the surveyor on 09/08/22 at 12:27 PM, the Consultant Pharmacist (CP) stated that short-acting insulin should be administered 15 minutes prior to a meal. If the medication was administered earlier and the meal tray does not come to the unit until later, the nurse should be offering crackers to the resident, unless the resident's diet required differently. The CP further stated that in the worst case scenario, the resident would have become hypoglycemic.
During an interview with the surveyor on 09/09/22 at 10:17 AM, LPN #1, the assigned nurse who administered the insulin at 7:27 AM and 7:28 AM, stated she administered Resident #168's Lispro insulin before the resident's breakfast tray came to the floor. LPN #1 further stated that she should have waited until the breakfast tray came to the floor.
During an interview with the surveyor on 09/09/22 at 12:09 PM, the DON stated that the nurse should have waited until the food trays were on the floor prior to administering insulin and that the nurse could have provided the residents crackers, pudding, applesauce, or a sandwich if the food trays were late. The DON stated that she expected the nurses wait until the food carts are on the unit prior to administering the insulin. The DON stated that if the insulin was given too early, that the resident would become hypoglycemic.
Review of the facility's policy titled Insulin Administration, revised 1/2022, reflected to check expiration date if drawing from an opened multi- dose vial and follow manufacturers recommendations for expiration after opening.
Review of the facility's policy titled Medication Administration, revised on 12/2021, revealed that the expiration date on the medication label must be checked prior to administering. The policy further reflected that medications must be administered in accordance with the orders, including any required time frame.
NJAC 8:39-29.2(d)
2(b). A review of the admission Record revealed Resident #93 was admitted to the facility with a diagnosis of Type 2 Diabetes Mellitus (DM).
A review of a Physician Order Sheet (POS) with active orders as of 09/12/22, revealed an order for Admelog Solution (a fast-acting mealtime insulin for DM) 100 Unit/ML, inject per sliding scale: if 0-150 = 0 units; 151-200 = 2 units, 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units if blood sugar (bs) > 400 call md (medical doctor), subcutaneously before meals and at bedtime for DM.
A review of the most recent MDS dated [DATE], revealed a BIMS score of 14/15, indicating Resident #93 was cognitively intact.
A review of the MAR dated 09/01/22-09/30/22 revealed the Admelog insulin order and was timed at 7:30 AM, 11:30 AM, 1630 (4:00 PM) and 2100 (9:00 PM). On the MAR under the date of 09/08/22, revealed that at 7:30 AM, Resident #93 had a blood sugar of 176 and nurses' initials and 2 units indicating that Resident #93 received 2 units of Admelog.
A review of the Location of Administration Report dated 09/01/22-09/30/22 revealed that on 09/08/22 Resident #93 received his/her insulin at 6:46 AM.
During an interview with the surveyor on 09/08/22 at 7:49 AM, Licensed Practical Nurse (LPN #1) who was assigned to Resident # 93, said she gave her insulin at 7:30 AM due to being on a sliding scale to Resident #93.
During an interview with the surveyor on 09/08/22 at 8:10 AM, Resident #93 said, I think so when asked if he/she received an insulin injection this morning. He/she also said, No, I have not had anything to eat today. I am not sure if I did get insulin, they usually wait until my breakfast tray comes.
On 09/08/22, the surveyor observed that Resident #93's breakfast tray arrived at 9:46 AM.
During an interview with the surveyor on 09/09/22 at 09:37 AM, LPN #1, the nurse who administered the insulin on 09/08/22 at 6:56 AM, said Yes, she gave the insulin before Resident #93's meal was on the unit. She went on to say that it depends on the blood sugar, but I usually hold the insulin until breakfast.
During a follow up interview with the surveyor on 09/09/22 at 10:15 AM, LPN #1 said, Yes I should have waited until his/her breakfast tray came to administer the insulin for sliding scale.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observation and interview it was determined that the facility had insufficient staffing in the kitchen to carry out the duties of the food service operations competently. This deficient pract...
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Based on observation and interview it was determined that the facility had insufficient staffing in the kitchen to carry out the duties of the food service operations competently. This deficient practice was evidenced by the following:
Cross-reference: F 760, F803, F804, F809 and F812
On 08/30/22 at approximately 10:00 AM, during the initial brief tour of the kitchen, the surveyor questioned the Director of Food Services (DOFS) why the kitchen staff were still assembling breakfast trays at 10:00 AM. The DOFS explained, We are normally done breakfast tray line by 9 AM. I had to call in (2) staff and borrow a cook from a sister facility. Staffing has been an issue for the month I've been here. It is slowing and affecting our production.
On 08/30/22 at 11:24 AM, the surveyor observed CNA #3 assisting resident #92 with the breakfast meal at 11:24 AM. The surveyor asked CNA #3 if that was breakfast or lunch. CNA #3 stated, It's breakfast. They didn't send a puree tray and we had to wait for another. We get the trays based on how many people show up to work in the kitchen.
On 09/01/22 at 10:22 AM, the surveyor conducted an interview with the DOFS in the kitchen to determine why the breakfast trays were late to arrive on the 2-C unit, as per the meal delivery schedule provided to the surveyor on entrance. The surveyor questioned the DOFS if trays had arrived late because the kitchen was short of staff, as previously told to the surveyor on the initial kitchen tour. The DOFS responded, Yes we are short of staff today. The trays arrived on the 2-C unit late because I don't have enough staff. I would say this is an industry wide problem. I am also short cooks. I have 5 people in orientation right now. I have made the administrator aware. He told me to look at an online job search company.
On 09/02/22 at 10:57 AM, the surveyor conducted an interview with the DOFS. The surveyor questioned the DOFS why some resident's (Resident #92) received their breakfast meal on a paper plate. The FSD responded, It's not a lack of plates, it's a lack of staff. The DOFS explained that he didn't have sufficient staff and all the dishes were not cleaned, therefore they utilized paper plates at the breakfast meal because there were not enough cleaned and sanitized regular dishware to serve the breakfast meal to all residents in the facility. The DOFS further explained that I'm the director, I'm the cook, and I'm the dishwasher right now.
On 09/06/22 at 09:55 AM, the surveyor interviewed the DOFS. The surveyor asked the DOFS if he was short of staff in the kitchen. The DOFS responded, Yes, we are short of staff today. We are short a cook, a dishware, and a server. I'm down 3 employees and I have had to be the cook almost daily. I do have a cook going through orientation. I didn't even to get to take a holiday. My Labor Day will be Friday. Saturday (09/03/2022) I had 5 call outs. I had to have nursing come down and help me.
On 09/08/22 at 10:08 AM, the surveyor interviewed the DOFS in the main dining room. The surveyor made the DOFS aware that a test tray had been conducted to assess food temperatures on the unit. The surveyor told the DOFS that the hot and cold food temperatures were not in compliance with industry standards. The DOFS replied, Ahh geeez, they were ice cold. You know it was hot when we made it. I'm losing it across the board. It boils down to manpower and I'm still short of staff right now. I had to call my assistant in because today was delivery day, and I didn't have enough staff. I don't get any days off unless I have an appointment.
On 09/09/22 at 10:43 AM, the surveyor interviewed the Assistant Food Service Director (AFSD). The surveyor asked the AFSD if the kitchen had adequate staffing on this day. The AFSD told the surveyor, We are very short today. We are down 4 positions, that's why the trays are late. I had to use paper products at breakfast because we would not be able to get the dishes clean in time for the lunch meal. The lunch meal would get pushed back too far, so we used paper products this morning to save time, which is because we are down 4 people today.
On 09/12/22 at 10:57 AM, the surveyor entered the kitchen accompanied by DOFS to assess the operation of the high temperature dish machine. The surveyor questioned the DOFS if the dish machine was in operation. The DOFS stated, Let me go fire it up. I'm 4 people short today.
On 09/12/22 at 01:38 PM, the surveyor interviewed the Licensed Nursing Home Administrator (LNHA). The surveyor asked the LNHA if the facility was experiencing a staffing shortage in the kitchen. The LNHA replied, Yes, we have staffing issues in the kitchen over the past month, but we have hired some new employees. The surveyor asked the LNHA if he was aware that the kitchen was 4 staff short on this day. The LNHA replied, I was not aware that we were 4 short today.
The facility did not provide a policy or procedure in relation to staffing of the food service operation.
The surveyor reviewed the facility pest management service invoice, dated 08/26/22. The invoice under General Comments/Instructions revealed the following by the technician on duty: From speaking with the employees, I understand that the kitchen is currently very short handed.
NJAC 8:39-17.3
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, it was determined that the facility failed to a) ensure that staff were following the menu over multiple meal observations which affected all reside...
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Based on observation, interview, and record review, it was determined that the facility failed to a) ensure that staff were following the menu over multiple meal observations which affected all residents of the facility and b) failed to obtain approval of menu substitutions in accordance with facility policy. This deficient practice was evidenced by the following:
1. On 08/30/22 at 11:24 AM, Surveyor #1 observed a Certified Nursing Assistant (CNA #3) assisting resident #92 with the breakfast meal. The surveyor asked CNA #3 if that was the breakfast or lunch meal. CNA #3 stated, It's breakfast. They didn't send a puree tray and we had to wait for another.
According to the admission Record, Resident #92 was admitted to the facility with diagnosis including but not limited to: Parkinson's disease, neurocognitive disorder with Lewy bodies, need for assistance with personal care, dysphagia (difficulty swallowing), and mild protein-calorie malnutrition.
According to the interdisciplinary care plan for Resident #92, Resident #92 was care planned for a nutrition problem: Related to Lewy body dementia, Parkinson's, mech altered diet, dependent on staff for feeding due to cognitive deficits with decline in function, difficulty swallowing, varying po (by mouth) intake, weight loss trend-now stable. Care planned interventions/Tasks included, Provide regular diet puree consistency Nectar/mildly thick liquids per MD order, Lactose free milk with meals, not lactose intolerant-prefers per [spouse], double portions, x 2 juice with meals and Health shake with meals.
During a tour of the facility on 08/30/22 at 11:25 AM, Surveyor #3 observed Resident #56 sitting up in bed. During the interview, the resident stated the meal trays were always missing items and that the trays often did not match the meal tickets.
Review of Resident #56's Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/17/2022, revealed Resident #56 had a Brief Interview for Mental Status score of 13 which indicated that the resident's cognitively intact.
On 08/31/22 at 09:33 AM, Surveyor #1 observed Resident #92 lying in bed with his/her eyes closed. Breakfast tray was at bedside on over the bed table. The breakfast tray consisted of pureed foods and nectar thickened liquids, as per meal ticket. No health shake was observed on Resident #92's meal tray.
On 08/31/22 at 1:06 PM, Surveyor #3 observed Resident #56's lunch meal service. The resident's tray was positioned on the overbed table next to the bed. Surveyor #3 observed resident #56's meal and tray observed noted with missing items. The resident did not receive a dinner roll or frosted slice of cake as documented on the meal ticket slip.
On 09/01/22 at 10:08 AM, Surveyor #1 observed CNA #3 provide 1:1 assist with eating the breakfast meal for Resident #92.
According to Resident #92's meal plan ticket for the breakfast meal, dated 09/01/22, Resident #92 was to receive the following diet: Regular, puree, with nectar/mild thick liquids. Review of the 09/01/22 breakfast meal ticket revealed that Resident #92 was to receive a 4oz Mighty Shake with his/her meal. Resident #92 received puree scrambled eggs, cream of wheat in a Styrofoam style take-out container, puree muffin, (2) nectar thick apple juices, (1) nectar thick lemon-flavored water and (2) margarines. Resident did not receive 4oz Mighty Shake as indicated on meal plan ticket. No salt and pepper were provided. The roommate of Resident # 92 also did not receive salt or pepper packet on tray, as observed by the surveyor.
On 09/01/2022 at 10:22 AM, Surveyor #1 conducted an interview with the Director of Food Services (DOFS) in the main dining room. The surveyor questioned whether the facility had Health/Mighty shakes in supply. The DOFS stated, We have Mighty/health shakes in supply, yes.
On 09/02/22 at 1:23 PM, Surveyor #3 observed Resident #56's lunch meal service. The resident's tray was positioned on the overbed table next to the bed. Surveyor #2 observed resident #56's meal and tray observed noted with missing items. The resident did not receive the chef choice of vegetables or dinner roll. Resident #56 stated he/she has made multiple requests for vegetables but did not always receive it.
On 09/06/2022 at 10:51 AM, Surveyor #1 observed resident #41 eating breakfast meal in their room. The surveyor observed Resident #41's meal tray and the breakfast meal was served on a Styrofoam plate. The meal consisted of scrambled eggs and a muffin, and hot cereal served in a take-out style Styrofoam box.
Surveyor #1 reviewed the facility provided menu for breakfast on 09/06/22, Week 4. The menu revealed that the breakfast meal on Tuesday 09/06/22 should have included bacon slices. Surveyor #1 went to the facility kitchen and conducted an observation and interview with the DOFS. The DOFS stated to Surveyor #1 when questioned whether there was bacon available for the breakfast meal, No, we ran out.
On 09/07/22 at 10:10 AM, Surveyor #1 observed that Resident #92 received his/her breakfast tray at 10:10 AM. Resident #92 received what CNA described as ground up pancakes. Meal ticket revealed that Resident was to receive egg and cheese biscuit and 4 oz Mighty Shake. Resident #92 had no Mighty/Health Shake on meal tray at this meal and received ground pancakes instead of a puree egg and cheese muffin.
A review of the menu for breakfast on 09/07/2022, revealed the following to be served: Apple juice, oatmeal, egg cheese biscuit, 2% milk, and coffee.
Observation of Resident #124's meal ticket revealed that they were to receive an egg and cheese biscuit as the breakfast entree on 09/07/2022. Resident #124 did not receive an egg and cheese biscuit and did not receive salt or pepper with the meal, as indicated on the meal ticket.
Surveyor #1 interviewed the DOFS on 09/07/22 at 10:22 AM. The surveyor explained to the DOFS that the breakfast menu on Wednesday 09/07/2022 revealed that facility residents were to receive an egg and cheese biscuit, however no residents received an egg and cheese biscuit at breakfast. The DOFS explained, You are correct, I can't argue with you, I was wrong. I didn't have enough eggs to make an egg and cheese biscuit today. I don't have enough biscuits, I didn't have enough to serve everybody, so I went with pancakes, white bread, and eggs. I substituted pancakes for the egg and cheeses biscuit. Surveyor #1 questioned whether the DOFS had approved the menu substitution with the facility Registered Dietitian (RD). The DOFS replied, I did not approve it with the dietitian. I came in at 5:30 AM. I never contacted the dietitian because she doesn't come in until 8 AM. Surveyor #1 then questioned whether it was facility policy to have menu substitutions approved by the facility RD before making changes to the menu. The DOFS responded, Yes, our facility policy is to have menu substitutions approved by the dietitian before making substitutions. I didn't this time because I was too busy cooking, because I'm short of staff. I'm a happy camper today because I have a cook in orientation. Surveyor #1 then asked the DOFS if a resident had a Mighty/Health shake on their menu was the kitchen supposed to provide the supplement for that resident. The DOFS explained, If the meal ticket stated a resident is to receive a Mighty shake, then it should be on the tray. Did we miss it? I have a whole case in the box. Surveyor #1 asked the DOFS if he was aware that the posted menu was not being served regularly. The DOFS answered, I am aware that I do not follow the facility menu. I follow it the best I can. I can make menu adjustments, but I am supposed to email a corporate employee for approval if I get them to her in time. I just found that out yesterday.
On 09/07/22 at 01:21 PM, Surveyor #1 observed Resident #4's lunch meal. The facility menu revealed that Resident #4 was to receive Jell-O w/ topping as the dessert at the lunch meal. Observation of the meal tray revealed Resident #4 did not receive Jell-O w/topping, no salt/no pepper, no Lactaid milk, and no water, as per the meal ticket.
In addition, Surveyor #2 observed the following at the lunch meal:
On 09/07/22 at 1:15 PM, Surveyor #2 observed Resident #12 lying in bed awake and alert. Resident #12 stated that he/she received breakfast around 10:30 AM and did not receive what was on the menu ticket. Resident #12 further stated that he /she was supposed to receive eggs and bacon but only received 3 little pancakes. Resident #12 stated I never get what is on the menu.
On 09/07/22 at 1:31 PM, Surveyor #2 observed Resident #12's lunch tray. Surveyor #2 observed the lunch tray included chocolate pudding and cranberry juice. Resident #12's meal ticket noted that the resident should have received Jell-O with topping and apple juice.
On 09/07/22 at 02:40 PM, Surveyor #1 interviewed the facility RD. Surveyor #1 questioned the RD what the purpose of a Mighty/House shake was and if they were a care planned intervention as prescribed for a resident to receive as part of the meal plan. The RD explained, The shake is put in place for supplemental calories and is to be provided at all meals including breakfast, lunch and dinner, as ordered. The RD further said, It is of benefit to the resident to have the extra calories and yes, it is a care planned intervention. Surveyor #1 asked the RD if she had ever completed any audits to assess whether residents who were prescribed the shakes were receiving them. The RD responded, I did audits to see if resident received them consistently with the previous DOFS. I have not had any issues yet with the present DOFS.
On 09/07/22 at 02:45 PM, Surveyor #1 further interviewed the facility RD. Surveyor#1 questioned the RD if she had been contacted by the DOFS to approve a menu substitution for the AM breakfast. The RD stated, I was asked to fill out the substitution log today before lunch. The surveyor asked the RD if she had ever been asked previously to approve any facility menu substitutions. The RD responded, This is the only time I was asked to fill out the substitution log since the new foodservice director started approximately a month ago. Surveyor #1 asked the RD if the DOFS was qualified to make menu substitutions without approval of the facility RD. The RD replied, He is not qualified to make substitution decisions. The facility policy for menu substitutions is that the RD should be contacted for approval of the menu change before the menu change is made. The DOFS did not call me this morning but had me approve the substitution around lunch time. 5:30 AM was a little early so he probably didn't want to call me at that time.
On 09/09/22 at 10:28 AM, the meal cart for breakfast arrived on unit 2-C at 10:28 AM. Resident #92 received his/her breakfast meal at 10:30 AM. Resident #92's meal ticket revealed that he/she was to receive a puree sausage patty x 2. The surveyor and CNA #4 both observed the breakfast tray and determined that no sausage puree was provided. The surveyor reviewed the facility menu for Friday 09/09/22 and the menu included sausage patty at the breakfast meal.
During a follow up interview with Surveyor #3 on 09/09/22 at 10:33 AM, Resident #56 stated the facility did not have enough staff in the kitchen which resulted in them receiving meals late. The resident added that at times breakfast got delivered around 10:30 AM and dinner got delivered around 6:00-6:30 PM. Resident #56 further stated that residents were not inform of menu changes, received the wrong items, or have items missing from the meal trays.
The surveyor reviewed the facility policy titled Tray Assembly Identification and Service Policy; last date revised: 1/2022. The following was revealed under the heading POLICY:
There will be a means of identifying resident meals and trays for therapeutic requirements and resident preferences.
The following was revealed under the heading PROCEDURE: Food Service
3. Meal tickets are printed for Breakfast, Lunch and Dinner daily and as needed during the day for new admits.
4. Resident diet order and food preferences are obtained and entered [Company] Meal Program.
5. Tickets are used to identify correct items for resident diet.
7. Food service staff will check trays for correct diets before the food carts are transported to their designated areas.
Nursing
11. The licensed nurse will confirm individual name and diet on the tray card/ticket to verify that the meal is served to the correct person, and check items on the plate/tray to assure accuracy for the therapeutic diets or texture or consistency modifications.
12. Nursing will check each food tray for the correct diet before serving the residents.
The surveyor reviewed the facility policy titled Menu Substitution Policy; last date revised: 4/2022. The following was revealed under the heading PROCEDURE:
1. The Food Services Manager, in conjunction with the Clinical Dietitian/Registered Diet Technician, may make food substitutions as appropriate or necessary. The Food Services Shift Supervisor on duty will make substitutions only when unavoidable.
2. Deviations from menus that have already been posted will be noted on menu substitution log form (including the reason for the substitution and/or deviation) in the kitchen and/or in the record book used solely for recording such changes. Menu substitutions will be approved and signed by the Registered Dietitian on the approved menu substitution log.
3. When in doubt about an appropriate substitution, the Food Services Manager will consult with the Dietitian prior to making the substitution.
NJAC 18:39-17.2 (b)
NJAC 18:39-17.4 (a) (1)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected most or all residents
Based on observation, interviews, and record review and review of other facility documentation, it was determined that the facility failed to serve meals at regular times in a manner that meets the re...
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Based on observation, interviews, and record review and review of other facility documentation, it was determined that the facility failed to serve meals at regular times in a manner that meets the residents needs for 2 of 2 residents (Resident #92 and Resident #74) observed during mealtime. This deficient practice was evidenced by the following:
Cross reference F760, F802
1. On 08/30/22 at 11:24 AM, while on the initial tour of the facility on the 2nd floor, the surveyor observed a Certified Nursing Assistant (CNA #3) assisting Resident #92 with eating his/her meal at 11:24 AM. The surveyor asked CNA #3 if that was the breakfast or lunch meal. CNA #3 responded, It's breakfast. They didn't send a puree tray and we had to wait for another. We get the trays based on how many people show up to work in the kitchen.
According to Resident #92's admission Record, Resident #92 was admitted to the facility with the following diagnoses: Parkinson's disease, aphasia (an inability to comprehend or formulate language), mild protein-calorie malnutrition, and need for assistance with personal care. In addition, the AR revealed that Resident #92 resided on the 2-C Unit of the facility.
According to the facility meal delivery schedule, provided to the surveyors at entrance conference, Resident #92's meal cart was scheduled as 2nd Floor C Cart 2 and was scheduled to leave the kitchen at 8:45 AM.
On 08/31/22 at 09:52 AM, CNA #3 was observed to assist breakfast to Resident #92.
On 09/01/22 at 09:28 AM, the surveyor arrived on the 2-C unit. Resident #92 had not received his/her breakfast meal tray at this time. A follow-up observation was conducted at 09:45 AM. The surveyor questioned CNA # 4 if she was still waiting on the C unit Cart 2 meal cart to arrive. CNA #4 responded, Yes, I am still waiting for a breakfast meal cart. This is typical and it has been like this since I have been here, which is a year. Sometimes on the weekend the breakfast trays won't arrive until lunch time.
On 09/01/22 at 01:17 PM, the surveyor went to Resident #92's room to observe the lunch meal. Resident #92's meal tray had not arrived at the unit at this time. According to the meal delivery schedule the 2nd Floor C Cart 2 was scheduled to leave the kitchen at 12:35 PM.
On 09/02/22 at 09:54 AM, the surveyor attempted to observe Resident #92 at the breakfast meal. Resident #92 had not received his/her breakfast tray from the kitchen at this time.
On 09/06/22 at 10:40 AM, Resident #92 was observed on the 2-C unit at 10:20 AM. Resident #92 had not received his/her breakfast tray at this time. An interview conducted with the facility Director of Food Services confirmed that the facility is short of staff in the kitchen and meal preparation/delivery is delayed because of being short staffed.
On 09/07/22, the surveyor observed Resident #92 had received his/her breakfast tray at 10:10 AM.
On 09/09/22 at 10:28 AM, the 2-C Cart 2 meal cart arrived on the unit for breakfast. Resident #92 received their breakfast meal tray at 10:29 AM.
2. On 09/01/22 at approximately 09:47 AM, Resident #74 asked CNA #4 when his/her breakfast would arrive. CNA #4 stated, One cart has been delivered but we are still waiting for the other cart to arrive with your meal. The surveyor conducted an interview with Resident #74 at 9:51 AM. Resident #74 told the surveyor, I'm hungry. I can't even get a coffee. The surveyor questioned Resident #74 if the meals were always late to arrive on his/her unit. Resident #74 replied, Yes, the meals arrive late. They don't give me a reason. Dinner arrives around 6:45 PM, sometimes a few minutes earlier. You get hungry. According to the facility meal delivery schedule, the 2nd floor C Cart 1 (all rooms on unit) was to leave the kitchen at 5:35 PM.
According to the admission Record, Resident #74 resided on the 2-C unit and had the following diagnoses: Multiple sclerosis, generalized anxiety disorder, need for assistance with personal care, and dementia in other diseases classified elsewhere with behavioral disturbance.
On 09/02/22 at 09:23 AM, the surveyor interviewed Resident #74 who said that he/she had not received his/her breakfast meal tray up to this point and told the surveyor, Hey, I'll let you know. I'm a wee bit agitated and hungry all the time.
On 09/06/22 at 09:46 AM, Resident #74 approached the surveyor in the C-Unit hallway in his/her wheelchair and stated, It would be nice to get my meal on time. Resident #74 had not received his/her breakfast meal at 9:47 AM. In addition, Resident #74 stated, I got dinner last night at 6:20 PM. They provided me with no reason why. It's every day.
On 09/12/22 at 01:38 PM the surveyor interviewed the facility Licensed Nursing Home Administrator (LNHA). The surveyor asked the LNHA if they had an issue with an understaffed facility kitchen. The LNHA responded, Yes, we have had staffing issues in the kitchen over the past month.
NJAC 8:39-17.4(a) (1)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following:
On 08/30/22 from 09:18 AM to 10:08 AM the surveyor, accompanied by the Director of Food Service (DOFS), observed the following in the kitchen:
1. On a middle shelf of a multi-tiered rack in the dry storage room a Styrofoam cup without a lid contained an unidentified liquid. The cup had not been labeled or dated. The DOFS stated, That doesn't belong there.
2. On a middle shelf (2) gallon containers of Fresh Kosher Chips had a received date of 6/24/21. The inside of the plastic gallon jug appeared to have a green/black mold and there was unidentified white debris surrounding the upper neck below the lid of the jug internally and unidentified debris externally. The DOFS stated, I would agree they appear to have mold. I'm going to throw them away.
3. On an upper shelf of a multi-tiered wire rack, an opened container of imported basil leaves had a received date of 4/10/21 and a UB (use by) date of 04/10/22. The DOFS stated, That is going in the trash. In addition (2) unopened containers of Ground ginger had a received date of 11/5/20 and 3 containers of ground cloves had a received date of 11/5/20. When questioned by the surveyor on how long herbs and spices are kept the DOFS stated, We usually go 2 years on those. I'm not sure what our policy is because I just got here. I have to check. The facility failed to provide a policy for shelf life of herbs and spices.
4. An opened cardboard box on the floor of the dry storage room contained plastic beverage lids. The plastic bag to the lids was removed and the lids were exposed. The FSD stated, They are for the trash. The surveyor asked why they weren't in the trash and still in the dry storage room. The DOFS stated, Because I'm not done yet.
5. A stand up fan next to the designated handwashing sink was turned on and blowing. The fan had a large accumulation of dust and unidentifiable debris on the blade guard grills and the blades of the fan.
6. A cleaned, sanitized and re-assembled meat slicer on a metal prep table had no cover and was exposed to dust and splash contamination. When interviewed the DOFS stated, Yes sir, our policy is to keep it covered when not in use.
7. The ice cream freezer had a large buildup of ice and was stained with brown and pink unidentified substances throughout the bottom and sides of the freezer. The freezer was observed to contain chocolate and strawberry ice cream. The surveyor questioned the DOFS how often the ice cream freezer is cleaned. The DOFS replied, I try to put it on the schedule weekly. The surveyor questioned if it was currently on the weekly schedule. The DOFS explained, No sir. I'm still trying to institute policies.
8. In the walk-in freezer on an upper shelf, a yellow/green rag was in front of a box of frozen broccoli. On a lower shelf, a bag of unopened frozen wax beans was removed from its original container and had no dates. The wax beans had a significant ice buildup on the inside of the bag and wax beans. On an upper shelf an opened bag of frozen shrimp was wrapped in plastic wrap. The shrimp had no dates. On the same shelf on the opposite side of the refrigerator, a bag of meatless burgers was opened and exposed to the air.
On 09/02/22 at 10:57 AM, the surveyor went to the kitchen to interview the DOFS. The surveyor observed the DOFS in the kitchen from the opened entry door. The DOFS had no hair net, and his hair was fully exposed.
On 09/06/22 from 10:01 AM to 10:16 AM the surveyor, accompanied by the Registered Nurse (RN) observed the following on the 2nd floor resident pantry:
1. The Temperature Log for Refrigerator and Freezer, dated Sept. 22 was incomplete. The following temperatures were not recorded: PM temp on 9/1, AM temp on 9/3, AM temp on 9/4, and AM temp on 9/5 for the refrigerator. The freezer temperatures were not completed on the following dates: 9/1 PM, 9/3 AM, 9/4 AM, 9/5 AM. On interview the RN stated, I'm not sure who records the temperatures. I believe the 11-7 shift is responsible for the AM temperatures and the PM temperatures are completed by the 3-11 shift. Can I double check? The RN then confirmed that the information was accurate and further explained that the unit managers during the day shift are to check to see if the temperatures were completed.
2. On a middle shelf of the pantry refrigerator a black plastic take-out style container with a clear lid contained what appeared to be rice and another unidentifiable food. The container had no name, date, or use-by date. On interview the RN stated, Yes, things are to be thrown away in 48 hours. Our policy is to label and date everything. I'm going to throw that away.
On 09/06/22 at 11:04 AM, the surveyor entered the kitchen to interview the DOFS. Upon entering the kitchen, the surveyor observed a female staff with lengthy hair reaching their midback. The female staff did not have a hairnet and their hair was fully exposed. In addition, the surveyor observed a male staff standing in the kitchen. The male staff had lengthy hair. The male staff was not wearing a hair net and their hair was fully exposed. The DOFS was observed to instruct the employees to don hairnets in the presence of the surveyor.
On 09/07/22 at 10:22 AM, the surveyor went to the kitchen to conduct an interview with the DOFS. Upon arrival to the kitchen the surveyor observed the DOFS in the kitchen. The DOFS had no hair net, and his hair was fully exposed. When interviewed the DOFS stated, You are correct, I can't argue with you I was wrong.
On 09/08/22 from 07:24 AM to 08:17 AM the surveyor, accompanied by the DOFS observed the following in the kitchen:
1. An unidentified white debris was on the coffee machine starting at the faucet and extending down from the faucet to the base of the machine. On the top of the coffee machine the surveyor observed what appeared to be dried coffee grounds and brown stains that were dry. The machine was currently in use for the breakfast meal.
2. On a middle shelf of a multi-tiered drying rack, a stack of sheet pans was determined to be wet to the touch between sheet pans with a water-like substance, termed wet nesting. The bottom of the second sheet pan in the stack was covered in a greasy unidentified substance and was removable by touch. The DOFS stated, Yep, they are wet. Anytime I put my hand on something and it comes away wet, it's wet.
3. In the dish room on the clean end of the table where dishes exit the machine after being cleaned and sanitized, an unopened bottle of [stores name] Frappuccino was observed next to the clean dishware. In addition, 6 stacks of pellet lids and bases, used to hold and keep plates of resident food warm during transportation, were not stacked in an inverted position and were exposed to contamination.
4. A deep 1/2 pan in the 2-door refrigerator #1 contained sliced deli ham. The 1/2 pan of ham was covered with clear plastic wrap and had no dates. In addition, on the lower right bottom of the refrigerator a plastic storage type bin with a hard plastic snap-on cover contained tuna salad. The container had no dates.
5. An opened pack of orange cheeses slices in the 2-door refrigerator #2 was not completely wrapped and was exposed on an upper shelf. The cheese had no open or use by date. On a lower shelf an opened container of macaroni salad had no lid and was exposed. The top surface of the macaroni salad was observed to be dried out. On an upper left shelf an opened container of Peeled Garlic had a manufacturer's date of MAR/05/22. The garlic did not have an opened or use by date. A 1/4 pan on a lower shelf contained what appeared to be sausage patties (7). The pan was covered with plastic wrap. The pan had no dates. On the upper right shelf an opened package of white cheese slices was wrapped in plastic wrap and had no dates. On the same shelf an opened and previously sliced deli turkey was wrapped in plastic wrap and had no dates. When interviewed the DOFS stated, When in doubt, throw it out.
6. The stand-up fan in front of the designated hand washing sink was observed to have dust and unidentified debris on the fan blades and fan blade guard, as previously observed on the initial kitchen tour on 08/30/22
7. On a windowsill next to the food production area table/shelf an opened and exposed box of corn starch was observed next to a bottle of cleaner/disinfectant, a gallon jug of multi-Purpose cleaner and Deodorizer, and a bottle of [brand name] Classic Antibacterial spray cleaner. In addition, a fly swatter was also on the windowsill next to the opened box of corn starch. On interview the DOFS proceeded to remove the items from the windowsill and dispose of the corn starch.
On 09/08/22 from 09:39 AM to 9:49 AM, the surveyor, accompanied by the DOFS, observed the following in the kitchen:
1. At 09:41 AM the surveyor observed an Activity Aide (AA) enter the kitchen from the dining room door. The activity aide had shoulder length hair. The activity aide did not have a hair net and all their hair was exposed. On interview the surveyor verbalized that she needs a hair net to enter the kitchen. The AA stated, I know.
On 09/12/22 from 10:57 AM to 11:26 AM the surveyor, accompanied by the DOFS observed the following in the kitchen:
1. Prior to entry to the kitchen the surveyor questioned the DOFS in the hallway if the dish machine was in operation. The DOFS stated, Let me go fire it up. I'm 4 people short today. Upon entry to the dish room the surveyor observed a white unidentified substance on the floor beneath the dish machine and under the table where the dirty dishware is scraped and sprayed prior to dishwashing. The surveyor also observed cleaned and sanitized silverware, plates, and pellet covers on the clean end of the dish machine. The silverware, plates and pellets were not bagged, covered, inverted, or placed on the drying rack and were exposed. During observation of the dish room the surveyor observed a live cock roach on the cleaned and sanitized end of the dish machine table in addition to a dead cock roach in the same area. The DOFS stated that the exterminators were here this morning and had just sprayed the floor of the dish room. The surveyor observed a bottle of Zevo ant, roach, and fly insect killer on the top of the dish machine and an opened bag of Herr's barbecue potato chips. The DOFS stated They shouldn't be there.
2. The base of the dish machine below the exit area for cleaned and sanitized dishes was covered with a white unidentified substance.
3. The wall to the left of the entry door from the hallway was observed to be stained with a brownish unidentified substance, extending from the baseboard tiles and up the wall. In addition, the wall behind the spraying area where dishes are washed down before being loaded into the dish machine had a black unidentified substance extending up the wall.
4. The surveyor reviewed the High Temperature Dish Machine Temperature Log, undated. The log revealed that the kitchen staff had not recorded any dish machine temperatures for the AM, Midday, or PM since 09/06/22, a period of 6 days. When interviewed the DOFS stated, I didn't know that they were not being recorded but I do now. Our policy is that temperatures are to be recorded prior to the initiation of dishwashing to ensure the machine runs at proper temperature.
5. A four wheeled 3 shelved utility cart was next to the 3-compartment sink. The cart had an unidentified white substance spilled on the middle and lower shelf. On the floor at the base of the wheel of the cart was an empty chemical spray bottle. A utility closet used to store paper goods had the door open. The surveyor observed a large stack of coffee filters that were removed from their original packaging and were exposed.
The surveyor reviewed the facility policy titled Poisonous and Toxic Materials, revised December 2008. The following was revealed under the heading Policy Statement:
Poisonous and toxic materials shall be stored in areas away from the food service area.
The following was revealed under the heading Policy Interpretation and Implementation:
1. Only poisonous and toxic materials that are required to maintain kitchen sanitation shall be permitted in the pot washing and dishwashing areas but may not be stored or used in the presence of food.
3. When not in use, poisonous and toxic materials will be stored on shelves that are used for no other purpose, or stored in a place outside the food storage, food preparation, and cleaned equipment and utensil storage areas.
The surveyor reviewed the facility policy titled Cleaning Policy; last date revised: 01/2020. The following was revealed under the heading POLICY:
The nutrition and food services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule.
The following was revealed under the heading PROCEDURE:
1. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department.
2. Tasks shall be designated to be the responsibility of specific positions in the department.
3. Staff will be trained on the frequency of cleaning as necessary.
4. A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed.
5. Staff will be held accountable for cleaning assignments.
The surveyor reviewed the facility provided Daily Cleaning Schedule* (*Clean all items at least daily, preferably after each use.) for the weeks of August 1-4 and September 1 and 2. The Daily Cleaning Schedule did not address the coffee maker. Review of the facility provided Monthly Cleaning Schedule, dated [DATE] revealed that the fan was cleaned on 08/20/22. The schedule also revealed that baseboards were cleaned on 08/09/22 and walls were also cleaned on 08/09/22.
The surveyor reviewed the facility policy titled Food-From Outside, last date revised: 1/2022. The following was revealed under the heading PROCEDURE:
9. All refrigeration units will have internal thermometers to monitor temperatures. All units must be maintained at internal temperatures that are deemed safe for food storage according to state and federal standards.
11. Food brought by family/visitors that is left with the resident to consume later will (sic) labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. (Label will identify resident name, room number, item, date received and discard date)
All refrigerated foods will be discarded within 48 hrs.
b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item, and the discard date.
12. Nursing staff will monitor resident's room, unit pantry, and refrigeration units for food and beverage disposal.
13. The nursing staff will discard perishable foods on or before the discard date.
14. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).
The surveyor reviewed the facility provided policy titled DISH WASHING AND STORAGE POLICY, last date revised: 10/2021. The following was revealed under the heading POLICY:
Dishes, pots and pans will be washed and dried using procedures, chemicals and equipment that result in clean, sanitized dishes, pans, flatware and utensils.
The following was revealed under the heading PROCEDURE:
Dish Machine Washing:
3. Dish machine temperatures are logged at each meal on the Dish Machine Temperature Log.
4. Staff will monitor dish machine temperatures throughout the dishwashing process.
Dishes, pots, pans, utensils and flatware must be air dried before being stored. Do not dry with towels.
6. Dish machine is drained and cleaned between each meal service period.
7. Employees are trained in proper dishwashing and drying procedures.
The surveyor reviewed the facility policy titled FOOD STORAGE; last date revised: 03/09/22. The following was revealed under the heading PROCEDURE:
5. Chemicals must be clearly labeled, kept in original containers, when possible, kept in a locked area and stored away from food.
7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods.
a. Old stock is always used first (first in-first out method).
12. Leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be clearly labeled and dated before being refrigerated. Leftover food is used within 24-72 hours or discarded as per the 2013 Federal Food Code.
13. Refrigerated food storage:
d. Each nursing unit with a refrigerator/freezer unit will be supplied with thermometers and monitored for appropriate temperatures.
f. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.
14. Frozen Foods:
c. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.
The surveyor reviewed the facility policy titled SANITIZATION POLICY, last date revised: 02/2021. The following was revealed under the heading POLICY:
The food service area shall be maintained in a clean and sanitary manner.
The following was revealed under the PROCEDURE heading:
All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects.
3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions after each use.
Equipment near prep areas shall remain covered once cleaned and air dried to prevent cross contamination.
10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical.
17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work area during all tasks.
The surveyor reviewed the facility pest management service invoice, dated 08/26/22. The invoice under General Comments/Instructions revealed the following by the technician on duty: While the building itself looks attractive inside the kitchen is in a very unsanitary condition. From speaking with the employees I understand that the kitchen is currently very short handed. My concern is that should a regulatory agency enter the building they would likely cite the facility for the unsanitary conditions. The kitchen cleanliness needs to improve ASAP.
The surveyor reviewed the facility policy titled FOOD TEMPERATURES POLICY, last date reviewed: 2/2022. The following was revealed under the heading POLICY:
Food temperatures of cold and hot food items will be recorded on all menu items and substitutions for meal service to maintain a high level of quality assurance and to monitor potentially hazardous food temperatures as per state and federal health regulations thus ensuring that foods are provided in a safe, palatable manner.
The following was revealed under the heading PROCEDURE:
2. Meal temperatures will be recorded at the beginning of meal service to ensure proper temperatures are achieved and repeated midway through at point of service if meal service exceeds 2 hours.
NJAC 18:39-17.2(g)
Feb 2021
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined the facility failed to; a) mainta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of other facility documentation, it was determined the facility failed to; a) maintain a clean and sanitary environment and b) failure to adhere to facility wheelchair cleaning schedule. This deficient practice was identified for 2 of 6 units in the facility and evidenced by the following:
a. On 2/19/21 at 1:15 PM, the surveyor observed a clear liquid coming from the lunch cart, spilled in the middle of the 2A hallway. The surveyor observed 3-4 Certified Nursing Assistants (CNA) who walked by the spill without cleaning it up. Dirt and debris were observed in the hallway of 2A and 2B units as well as in more than half of resident's rooms. The surveyor observed the countertop of the 2nd floor nurses station had dirt and a dried sticky substance on the surface.
On 2/22/21 at 9:55 AM, the surveyor observed the following: room [ROOM NUMBER]A 209B resident's trash overflowing with no bags in the trash cans. An old broom was left in the corner of the room and dirt and debris was on the floor. The surveyor observed the privacy curtain had a brown substance stain on the bottom of the curtain. The resident stated, Nobody came yesterday (2/21/2021) to clean the room or empty the trash.
On 2/22/21 at 10:00 AM, the surveyor observed the following:
The 2A unit hallway which had spilled coffee on floor and a crouton laying on floor outside of the resident's room.
The 2A unit hallway had an odor of urine.
In room [ROOM NUMBER]A 208, the surveyor observed debris and latex gloves laying on the floor.
In room [ROOM NUMBER]A 210 the surveyor observed debris on floor.
In room [ROOM NUMBER]A 211 the surveyor observed discarded gloves and debris on the floor. Outside of the same room was a water cup sitting on the handrail directly outside the door.
On 2/22/21 at 11:07 AM, the surveyor observed the soiled utility room on second floor with a Licensed Practical Nurse (LPN). The soiled utility room had laundry bags piled up the wall and overflowing out of the soiled laundry basket. There was no soap or paper towels by the sink. There was trash and debris on the floor. The LPN went to wash her hands and stated, Oh, there's no soap or paper towels in here.
On 2/23/21 at 9:12 AM, the surveyor interviewed the Director of Housekeeping (DH) who said the units were cleaned once a day. which included the resident rooms, and the high touch areas twice daily. The DH was not aware that the resident rooms were not cleaned on Sunday 2/21/2021. The DH stated that if the resident is sleeping, the staff will sometimes, go after lunch, but if the hallway was already done, then they won't double back to clean the rooms. The surveyor asked the DH about the soiled laundry in the soiled utility room that was piled up the wall and overflowing out of the basket. The DH stated the yellow bags containing resident laundry get done on Tuesday, Wednesday, and Thursday. The staff was required to complete a daily mop of the floors and hallway, wipe down high touch areas daily. He went on to say there are three housekeeping staff assigned to each hall on the 2nd floor and then they split the last hall into thirds. The DH stated he completed audit rounds three times a week. He said when he completes the audits and finds a problem, it was corrected immediately. The DH stated the housekeeping staff was on the floor 2 times a day from 9-11 AM, and then 12:30-2:45 PM.
On 2/23/21 at 10:38 AM the surveyor received the 7-step Cleaning Process facility policy, undated, 1) Pull Trash/Recycle: Remove liners and reline all waste containers. Clean waste receptacles, 5) Dust Mop Floor: Dust behind all furniture and doors. Move whatever is possible, and 6) Damp Mop: Mop out corners to prevent build.
b. On 2/17/2021 at 11:25 AM, Resident #151 was observed to be seated in a custom wheelchair at the end of C unit hallway on the second floor. Resident #151's wheelchair was observed to be covered in areas with an unidentified white substance on the lower wheelchair frame and the right wheel of the wheelchair.
On 2/23/2021 at 8:33 AM the surveyor observed Resident #151 again seated in his/her custom wheelchair on the second floor C unit hallway. The surveyor again observed the same white unidentified substance on the wheelchair frame and right wheel, as previously observed on 2/17/2021.
On 2/23/2021 at 10:41 AM the surveyor interviewed the Director of Housekeeping (DH) who stated, We clean wheelchairs once a month. We clean 240 chairs a month and we clean 8 chairs per day according to our monthly schedule. The HD further stated, If a chair gets dirty, we can also clean it that day. The HD provided the surveyor with a copy of the facility Wheel Chair Schedule February 2021. The schedule revealed that Resident #151 was to have had their wheelchair cleaned on the 17th of February 2021.
On 2/24/2021 at 10:25 AM the surveyor interviewed the Director of Nursing (DON) who stated, The wheelchair was not cleaned on the 17th because they (housekeeping staff) were focused on the snowstorm.
NJAC 8:39-31.4(a)(f)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and cons...
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Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner designed to prevent food borne illness. This deficient practice was evidenced by the following:
On 2/16/2021 from 9:24 to 10:00 AM the surveyor, accompanied by the Food Service Director (FSD), observed the following in the kitchen:
1. In the dry storage area on a middle shelf of a three-tiered storage rack a can of [NAME] Mandarin Oranges had a significant dent on the bottom seam. The FSD removed the can to the designated dented can area.
2. In the walk-in refrigerator on a middle shelf a bag of frozen mixed vegetables was removed from its original container. The mixed vegetables had no date. On interview the FSD stated, They should have been dated when they were removed from the original container. The FSD threw the frozen mixed vegetable in the trash. In the same walk-in freezer on a rear middle shelf, a bag of frozen broccoli was removed from the original container and a frozen pie covered with plastic wrap was removed from its original container. No dates were observed on the frozen broccoli or pie. On interview the FSD stated, They should be dated when they are removed from their original box. The FSD threw the pie and frozen broccoli in the trash.
3. In the designated hand washing sink area, the step trash can (a trash can that is opened by stepping on a foot pedal) was observed to be broken. The surveyor observed a dietary aide (DA) perform hand washing. Upon completion of hand washing, the DA grabbed a hand towel and dried their hands and proceeded to turn off the faucet with the hand towel. The DA then proceeded to step on the foot pedal to open the trash can, however the lid would not open because the lid was broken from the trash can hinge. The DA had to go to another trash can to throw away the dirty hand towel.
4. A cleaned, and sanitized meat slicer was on top of a counter in the prep area. The meat slicer was not in use, per the FSD. The meat slicer was uncovered and exposed. On interview the FSD stated, We cover the slicer when not in use with a plastic bag.
5. A clean and sanitized stack of large metal bowls was stored on a middle shelf of a multi-tiered storage rack next to the three-compartment sink. The bowls were stored facing upward exposing the inside of the bowl to possible contamination. On interview the FSD stated, 'They should be stored in the inverted position. On the same shelf, (4) small frying pans and (1) large frying pan that had been cleaned and sanitized were not stored in the inverted position and the cooking surface was exposed. On interview the FSD stated, I'm going to rewash and sanitize all of these bowls and pans.
On 2/22/21 from 10:09 to 10:13 AM the surveyor, accompanied by the Registered Nurse/Unit Manager (RN/UM) observed the following on the second floor B Unit Pantry:
1. In an upper cabinet above the pantry sink, a sleeve of Styrofoam cups was removed from their plastic covering and exposed. The RN/UM stated, I'm throwing them out. The RN/UM threw the Styrofoam cups into the trash in the presence of the surveyor.
The surveyor reviewed the Centers Health Care policy titled DENTED CANS, with revised date of 05/2019. Under the PROCEDURE heading the following was revealed:
1. Identify all unacceptable dented cans.
2. Place all dented cans on a designated shelf marked Dented Cans.
The surveyor reviewed the facility policy titled Food Storage, with a date originated: 6/2/2016 and no revised date. The following was revealed under the heading Policy Interpretation and Implementation:
1. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).
The facility was unable to provide a policy for storage of cleaned and sanitized equipment that is not in use.
NJAC 8:39-17.2(g)
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most New Jersey facilities.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s). Review inspection reports carefully.
- • 55 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade F (23/100). Below average facility with significant concerns.
- • 70% turnover. Very high, 22 points above average. Constant new faces learning your loved one's needs.
Bottom line: Trust Score of 23/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Deptford Center For Rehabilitation And Healthcare's CMS Rating?
CMS assigns Deptford Center for Rehabilitation and Healthcare an overall rating of 2 out of 5 stars, which is considered below average nationally. Within New Jersey, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Deptford Center For Rehabilitation And Healthcare Staffed?
CMS rates Deptford Center for Rehabilitation and Healthcare's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 70%, which is 24 percentage points above the New Jersey average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Deptford Center For Rehabilitation And Healthcare?
State health inspectors documented 55 deficiencies at Deptford Center for Rehabilitation and Healthcare during 2021 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 52 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Deptford Center For Rehabilitation And Healthcare?
Deptford Center for Rehabilitation and Healthcare is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 240 certified beds and approximately 225 residents (about 94% occupancy), it is a large facility located in DEPTFORD, New Jersey.
How Does Deptford Center For Rehabilitation And Healthcare Compare to Other New Jersey Nursing Homes?
Compared to the 100 nursing homes in New Jersey, Deptford Center for Rehabilitation and Healthcare's overall rating (2 stars) is below the state average of 3.2, staff turnover (70%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Deptford Center For Rehabilitation And Healthcare?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Deptford Center For Rehabilitation And Healthcare Safe?
Based on CMS inspection data, Deptford Center for Rehabilitation and Healthcare has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in New Jersey. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Deptford Center For Rehabilitation And Healthcare Stick Around?
Staff turnover at Deptford Center for Rehabilitation and Healthcare is high. At 70%, the facility is 24 percentage points above the New Jersey average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Deptford Center For Rehabilitation And Healthcare Ever Fined?
Deptford Center for Rehabilitation and Healthcare has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Deptford Center For Rehabilitation And Healthcare on Any Federal Watch List?
Deptford Center for Rehabilitation and Healthcare is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.